Provider Demographics
NPI:1538512314
Name:LOPEZ, LIDIA YESENIA (MPAS, PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LIDIA
Middle Name:YESENIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2115 KRAMER LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-4013
Mailing Address - Country:US
Mailing Address - Phone:512-978-9000
Mailing Address - Fax:
Practice Address - Street 1:2529 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5466
Practice Address - Country:US
Practice Address - Phone:512-978-9500
Practice Address - Fax:512-901-9708
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA10630363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant