Provider Demographics
NPI:1710947650
Name:LOPEZ, JERRY (PA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5295
Mailing Address - Country:US
Mailing Address - Phone:512-439-1000
Mailing Address - Fax:512-439-1081
Practice Address - Street 1:4700 SETON CENTER PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5295
Practice Address - Country:US
Practice Address - Phone:512-439-1000
Practice Address - Fax:512-439-1081
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA03921363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8B7874Medicare ID - Type Unspecified
TXS91673Medicare UPIN
TX8B7875Medicare ID - Type Unspecified