Provider Demographics
NPI:1669453031
Name:LOPEZ, NANCY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPA-C
Mailing Address - Street 1:2100 STANTONSBURG RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2818
Mailing Address - Country:US
Mailing Address - Phone:252-752-5077
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-847-0782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010394363AS0400X
NC0010-06595363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02716833Medicaid
NYA400108780Medicare PIN
NYQ59424Medicare UPIN