Provider Demographics
NPI:1659846988
Name:LOPEZ, GABRIEL THOMAS
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:THOMAS
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 1:7419 W PLANADA LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-5886
Mailing Address - Country:US
Mailing Address - Phone:602-571-3364
Mailing Address - Fax:
Practice Address - Street 1:7419 W PLANADA LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-5886
Practice Address - Country:US
Practice Address - Phone:602-571-3364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-13
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ7939363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program