Provider Demographics
NPI:1720387574
Name:LOPEZ, EVELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 S MANDERLY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-3108
Mailing Address - Country:US
Mailing Address - Phone:714-504-8803
Mailing Address - Fax:
Practice Address - Street 1:430 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1829
Practice Address - Country:US
Practice Address - Phone:626-859-2851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-18
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant