Provider Demographics
NPI:1033640685
Name:LOPEZ, BENITO (PA-C)
Entity Type:Individual
Prefix:
First Name:BENITO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4113 CROSSPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-1803
Mailing Address - Country:US
Mailing Address - Phone:956-603-1555
Mailing Address - Fax:
Practice Address - Street 1:4113 CROSSPOINT BLVD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1803
Practice Address - Country:US
Practice Address - Phone:956-603-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA11140363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA11140OtherTEXAS MEDICAL BOARD