Basic Information
| Provider Information | |||||||||
| NPI: | 1497296594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIVA | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 44TH ST SE | ||||||||
| Address2: | |||||||||
| City: | KENTWOOD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495085008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166851808 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1246 MADISON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495071761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601008130 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.