Provider Demographics
NPI:1083479372
Name:LOPEZ, KANDYCE (PA)
Entity Type:Individual
Prefix:
First Name:KANDYCE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 CORTEZ RD W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210-3121
Mailing Address - Country:US
Mailing Address - Phone:941-500-3100
Mailing Address - Fax:941-500-3113
Practice Address - Street 1:4216 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3121
Practice Address - Country:US
Practice Address - Phone:941-500-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-16
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118394363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical