Healthcare Provider Details

I. General information

NPI: 1922183532
Provider Name (Legal Business Name): JAIME LOPEZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 MAIN ST
WINTERS CA
95694-1722
US

IV. Provider business mailing address

310 MAIN ST
WINTERS CA
95694-1934
US

V. Phone/Fax

Practice location:
  • Phone: 530-795-4377
  • Fax: 530-795-3054
Mailing address:
  • Phone: 530-795-5200
  • Fax: 530-795-9541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: