Provider Demographics
NPI:1568558963
Name:LOPEZ WYSONG, LORENZA NONE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LORENZA
Middle Name:NONE
Last Name:LOPEZ WYSONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3533 CANYON DE FLORES, STE A
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-5366
Mailing Address - Country:US
Mailing Address - Phone:520-803-7640
Mailing Address - Fax:520-803-7886
Practice Address - Street 1:3533 CANYON DE FLORES, STE A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-5366
Practice Address - Country:US
Practice Address - Phone:520-803-7640
Practice Address - Fax:520-803-7886
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1896363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ105294Medicare PIN