Provider Demographics
NPI:1255301636
Name:LOPEZ, ANTONIA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:ANTONIA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 TREASURE DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-4426
Mailing Address - Country:US
Mailing Address - Phone:619-462-6081
Mailing Address - Fax:
Practice Address - Street 1:4950 TREASURE DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-4426
Practice Address - Country:US
Practice Address - Phone:619-312-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant