Provider Demographics
NPI:1659526911
Name:LOPEZ, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 GARVEY AVE STE 5B
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-4535
Mailing Address - Country:US
Mailing Address - Phone:626-579-0707
Mailing Address - Fax:626-579-0235
Practice Address - Street 1:11725 GARVEY AVE STE 5B
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-4535
Practice Address - Country:US
Practice Address - Phone:626-579-0707
Practice Address - Fax:626-579-0235
Is Sole Proprietor?:No
Enumeration Date:2008-11-28
Last Update Date:2008-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20039363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant