Provider Demographics
NPI:1912533076
Name:LOPEZ, JASON O
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:O
Last Name:LOPEZ
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-821-8038
Mailing Address - Fax:813-974-0483
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-821-8038
Practice Address - Fax:813-974-0483
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024865363A00000X
FLPA9117464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1171308OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANT (NCCPA)
FL119492900Medicaid
FL9IGTXOtherBCBS
NY024865OtherNYS EDUCATION DEPTARMENT OFFICE OF PROFESSIONS