Provider Demographics
NPI:1013426857
Name:LOPEZ, EDDY JOSE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EDDY
Middle Name:JOSE
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11804 ROSSMAYNE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5657
Mailing Address - Country:US
Mailing Address - Phone:813-390-1935
Mailing Address - Fax:
Practice Address - Street 1:4507 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2703
Practice Address - Country:US
Practice Address - Phone:813-876-4100
Practice Address - Fax:813-876-4153
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant