Basic Information
Provider Information | |||||||||
NPI: | 1184053423 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIVERA | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BIBB | ||||||||
OtherFirstName: | REBECCA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2700 STANLEY GAULT PKWY STE 129 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402235176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022534917 | ||||||||
FaxNumber: | 5024875751 | ||||||||
Practice Location | |||||||||
Address1: | 7725 HIGHWAY 62 STE 100 | ||||||||
Address2: |   | ||||||||
City: | CHARLESTOWN | ||||||||
State: | IN | ||||||||
PostalCode: | 47111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122800413 | ||||||||
FaxNumber: | 8122800465 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/07/2013 | ||||||||
LastUpdateDate: | 05/23/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10001839A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 300007796 | 05 | IN |   | MEDICAID | IN1189154 | 01 | IN | IN MEDICARE | OTHER | PA08679 | 01 | TX | TEXAS MEDICAL BOARD PA LICENSE NUMBER | OTHER |