Provider Demographics
NPI:1770549750
Name:LOPEZ, NIDIA (PA)
Entity type:Individual
Prefix:
First Name:NIDIA
Middle Name:
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:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0819
Practice Address - Street 1:1901 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5113
Practice Address - Country:US
Practice Address - Phone:915-544-6750
Practice Address - Fax:915-532-4259
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04792363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX809N07OtherBCBS
TXP00889868OtherRAILROAD MEDICARE
TX204427301Medicaid
TX205265608Medicaid
TX830N22OtherBCBS
TX205265601Medicaid
TXP00889868OtherRAILROAD MEDICARE
TX830N22OtherBCBS
TX204427301Medicaid
TX8L26311Medicare PIN