Provider Demographics
NPI:1164877346
Name:LOPEZ, RAFAEL A (SA-C)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:A
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12564 GILDED SUN DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79938-4648
Mailing Address - Country:US
Mailing Address - Phone:915-209-1025
Mailing Address - Fax:
Practice Address - Street 1:12345 JONES RD STE 102
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-4961
Practice Address - Country:US
Practice Address - Phone:915-209-1025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16-285246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant