Healthcare Provider Details

I. General information

NPI: 1639681745
Provider Name (Legal Business Name): MARTHA LOPEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 10/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 E CHAUNCEY LN STE 210
PHOENIX AZ
85054-3115
US

IV. Provider business mailing address

5931 W GRANADA RD
PHOENIX AZ
85035-4836
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-1117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: