Provider Demographics
NPI:1699855163
Name:LOPEZ, JOSE A (PA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3132 69TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1228
Mailing Address - Country:US
Mailing Address - Phone:718-920-5157
Mailing Address - Fax:
Practice Address - Street 1:MMC - DEPT. OF OBGYN
Practice Address - Street 2:111 EAST 210TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant