Provider Demographics
NPI:1629305883
Name:LOPER, AMBER WALLACE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:WALLACE
Last Name:LOPER
Suffix:
Gender:F
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 1:24514 VOLTERRA CT
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7361
Mailing Address - Country:US
Mailing Address - Phone:813-382-5181
Mailing Address - Fax:
Practice Address - Street 1:2815 W VIRGINIA AVE
Practice Address - Street 2:STE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6357
Practice Address - Country:US
Practice Address - Phone:855-834-6911
Practice Address - Fax:813-405-3004
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004025600Medicaid
12268338OtherCAQH
Y08MROtherBLUE CROSS
FLDD612XMedicare PIN