Provider Demographics
NPI:1720090061
Name:OSORIO-LOPEZ, JOSE EDUARDO (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:EDUARDO
Last Name:OSORIO-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 1:2370 CORPORATE CIR
Mailing Address - Street 2:STE 300
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7760
Mailing Address - Country:US
Mailing Address - Phone:702-910-3950
Mailing Address - Fax:
Practice Address - Street 1:6150 N US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-1806
Practice Address - Country:US
Practice Address - Phone:813-641-0007
Practice Address - Fax:813-641-0009
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291210400Medicaid
FL291210400Medicaid
FLE7609ZMedicare PIN