Provider Demographics
NPI:1679870695
Name:LOPEZ, MARIA E (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:E
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11711 COLLETT AVE APT 2526
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3790
Mailing Address - Country:US
Mailing Address - Phone:909-815-4227
Mailing Address - Fax:
Practice Address - Street 1:6200 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-2098
Practice Address - Country:US
Practice Address - Phone:951-358-0255
Practice Address - Fax:951-358-0218
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21391363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA 21391OtherDEPARTMENT OF CONSUMER AFFAIR