Provider Demographics
NPI:1326621608
Name:LOPEZ, THILO ERNESTO (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:THILO
Middle Name:ERNESTO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:SURGICAL ASSISTANT
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:435 FORT WASHINGTON AVE APT 1H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 E 153RD ST APT 30E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5262
Practice Address - Country:US
Practice Address - Phone:347-391-9503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical