Provider Demographics
NPI:1356936868
Name:LOPEZ, BIANCA MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:MICHELLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22137 W MESQUITE DR
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85326-5538
Mailing Address - Country:US
Mailing Address - Phone:602-814-6812
Mailing Address - Fax:
Practice Address - Street 1:13677 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2635
Practice Address - Country:US
Practice Address - Phone:623-882-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ8679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant