Provider Demographics
NPI:1649726852
Name:LOPEZ, SALVADOR (PA-C)
Entity type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HOYT LANE
Mailing Address - Street 2:
Mailing Address - City:WAPATO
Mailing Address - State:WA
Mailing Address - Zip Code:98951-9753
Mailing Address - Country:US
Mailing Address - Phone:509-388-3388
Mailing Address - Fax:
Practice Address - Street 1:310 HOLTON AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3208
Practice Address - Country:US
Practice Address - Phone:509-452-2508
Practice Address - Fax:509-452-7316
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
WAOA60743170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical