Provider Demographics
NPI:1235168857
Name:LOPEZ, FIDEL (PAA)
Entity Type:Individual
Prefix:
First Name:FIDEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 CLIFTON RD NE FL 3
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1060
Mailing Address - Country:US
Mailing Address - Phone:404-785-6670
Mailing Address - Fax:404-785-1362
Practice Address - Street 1:1405 CLIFTON RD NE FL 3
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1060
Practice Address - Country:US
Practice Address - Phone:404-785-6670
Practice Address - Fax:404-785-1362
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6541367H00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBDPZMedicare PIN