Provider Demographics
NPI:1700655701
Name:EBAGUA, ETINOSA LOPEZ
Entity Type:Individual
Prefix:
First Name:ETINOSA
Middle Name:LOPEZ
Last Name:EBAGUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 PIZZARO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1550
Mailing Address - Country:US
Mailing Address - Phone:818-350-9140
Mailing Address - Fax:
Practice Address - Street 1:1075 W BETTERAVIA RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455
Practice Address - Country:US
Practice Address - Phone:805-621-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical