Basic Information
Provider Information | |||||||||
NPI: | 1992337729 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RIVERA | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | MAUREEN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 70 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | MA | ||||||||
PostalCode: | 010621466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135299300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 70 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | FLORENCE | ||||||||
State: | MA | ||||||||
PostalCode: | 010621487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135299300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2020 | ||||||||
LastUpdateDate: | 02/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | PENDING | MA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
ID | Type | State | Issuer | Description | NONE | 01 |   | NONE | OTHER |