Healthcare Provider Details

I. General information

NPI: 1629210075
Provider Name (Legal Business Name): NOE MANUEL LOPEZ JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S ALVARADO ST
LOS ANGELES CA
90057-2904
US

IV. Provider business mailing address

1695 N SUNRISE WAY
PALM SPRINGS CA
92262-3701
US

V. Phone/Fax

Practice location:
  • Phone: 213-483-3600
  • Fax: 213-483-4555
Mailing address:
  • Phone: 760-323-2118
  • Fax: 760-416-1651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA20105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: