Healthcare Provider Details

I. General information

NPI: 1679870695
Provider Name (Legal Business Name): MARIA E. LOPEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 VAN BUREN BLVD
RIVERSIDE CA
92503-2098
US

IV. Provider business mailing address

11711 COLLETT AVE APT 2526
RIVERSIDE CA
92505-3790
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-0255
  • Fax: 951-358-0218
Mailing address:
  • Phone: 909-815-4227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21391
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: