Healthcare Provider Details

I. General information

NPI: 1659846988
Provider Name (Legal Business Name): MR. GABRIEL THOMAS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2018
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7419 W PLANADA LN
GLENDALE AZ
85310-5886
US

IV. Provider business mailing address

7419 W PLANADA LN
GLENDALE AZ
85310-5886
US

V. Phone/Fax

Practice location:
  • Phone: 602-571-3364
  • Fax:
Mailing address:
  • Phone: 602-571-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7939
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: