Provider Demographics
NPI:1932683919
Name:LOPEZ, GEMMA JUSTICE (PA-C)
Entity Type:Individual
Prefix:
First Name:GEMMA
Middle Name:JUSTICE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GEMMA
Other - Middle Name:LINDSAY
Other - Last Name:JUSTICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4881 E GRANT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2704
Mailing Address - Country:US
Mailing Address - Phone:520-829-6776
Mailing Address - Fax:520-829-6661
Practice Address - Street 1:36453 N GANTZEL RD STE 101
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-7340
Practice Address - Country:US
Practice Address - Phone:480-636-1225
Practice Address - Fax:480-636-8890
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72082081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ577172Medicaid