Provider Demographics
NPI:1578610614
Name:LOPES, JOHN EDWARD JR (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:LOPES
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5321
Mailing Address - Country:US
Mailing Address - Phone:989-953-4357
Mailing Address - Fax:
Practice Address - Street 1:4273 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-953-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004789363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004789OtherSTATE LICENSE
MI323930Medicare ID - Type Unspecified
MI5601004789OtherSTATE LICENSE