Provider Demographics
NPI:1639648322
Name:LOPEZ, MARIAH NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:NICOLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARIAH
Other - Middle Name:NICOLE
Other - Last Name:ISAACS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2939 SUNNY DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6333
Mailing Address - Country:US
Mailing Address - Phone:937-321-4494
Mailing Address - Fax:
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD STE 230
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7615
Practice Address - Country:US
Practice Address - Phone:937-433-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005750RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant