Basic Information
| Provider Information | |||||||||
| NPI: | 1821044751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIVAS | ||||||||
| FirstName: | ROSEMARY | ||||||||
| MiddleName: | ROMO | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1715 MCCULLOUGH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102255323 | ||||||||
| FaxNumber: | 2102257505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 MCCULLOUGH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782124046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102255323 | ||||||||
| FaxNumber: | 2102257505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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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 | 163WG0000X | 551810 | TX | Y | Nursing Service Providers | Registered Nurse | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 314283802 | 01 | TX | WELLMED MEDICAID | OTHER | TXB166822 | 01 | TX | WELLMED MEDICARE | OTHER |