Provider Demographics
NPI:1003175621
Name:LOPEZ, MARIE A (PA)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 NW MYHRE RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7662
Mailing Address - Country:US
Mailing Address - Phone:564-240-4200
Mailing Address - Fax:564-240-4299
Practice Address - Street 1:1950 NW MYHRE RD FL 3
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7662
Practice Address - Country:US
Practice Address - Phone:564-240-4200
Practice Address - Fax:564-240-4299
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363AS0400X
IA002283363AS0400X
WAPA61030329363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2154428Medicaid