Provider Demographics
NPI:1235374299
Name:LOPEZ, JOSIE (PAC)
Entity Type:Individual
Prefix:
First Name:JOSIE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 E BRAVO BLVD
Mailing Address - Street 2:
Mailing Address - City:ROMA
Mailing Address - State:TX
Mailing Address - Zip Code:78584-5720
Mailing Address - Country:US
Mailing Address - Phone:956-849-2176
Mailing Address - Fax:956-849-4155
Practice Address - Street 1:640 E BRAVO BLVD
Practice Address - Street 2:
Practice Address - City:ROMA
Practice Address - State:TX
Practice Address - Zip Code:78584-5720
Practice Address - Country:US
Practice Address - Phone:956-849-2176
Practice Address - Fax:956-849-4155
Is Sole Proprietor?:No
Enumeration Date:2008-12-04
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA01737OtherPA LIC.
TX1235374299Medicaid
TXTXB141169Medicare PIN