Basic Information
| Provider Information | |||||||||
| NPI: | 1730176181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVARD | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 S BROAD ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191483542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159529323 | ||||||||
| FaxNumber: | 2159521246 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 S BROAD ST | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191483542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159529323 | ||||||||
| FaxNumber: | 2159521246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN290911L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0019762810002 | 05 | PA | MEDICAID |