Provider Demographics
NPI:1912549379
Name:LOPEZ, BROOKE ELIZABETH (MMS, PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10290 N NORTH COUNTY BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8973
Mailing Address - Country:US
Mailing Address - Phone:801-899-3391
Mailing Address - Fax:
Practice Address - Street 1:10290 N NORTH COUNTY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:UT
Practice Address - Zip Code:84003-8973
Practice Address - Country:US
Practice Address - Phone:801-899-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12304844-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical