Provider Demographics
NPI:1194855817
Name:LOPEZ, JUANITA C (PA)
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:C
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 1:720 GOLDER AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4442
Mailing Address - Country:US
Mailing Address - Phone:432-337-3117
Mailing Address - Fax:432-337-3448
Practice Address - Street 1:720 GOLDER AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4442
Practice Address - Country:US
Practice Address - Phone:432-337-3117
Practice Address - Fax:432-337-3448
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03700174400000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA84785Medicare UPIN
TX8G3535Medicare ID - Type Unspecified