Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 11615 | PR |
NPI | 1033317656 |
---|---|
Provider Name | Grisell Rivera Alicea |
First Address | Ponce, PR 00717-1320 |
Second Address | Ponce, PR 00717-1321 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2007 |
Last Update Date | 04/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
11615 | MEDICAL LICENSE (01) | PR |