Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | H0762 | TX |
NPI | 1184690133 |
---|---|
Provider Name | Manuel A. Rivera |
First Address | Pewaukee, WI 53072 |
Second Address | Two Rivers, WI 54241-3900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/02/2006 |
Last Update Date | 12/03/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B56078 | (02) |