Healthcare Provider Details

I. General information

NPI: 1326186990
Provider Name (Legal Business Name): MIGUEL LOPEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S ANDREWS AVE FL 2
FORT LAUDERDALE FL
33316-2509
US

IV. Provider business mailing address

1700 NW 49TH ST STE 125
FORT LAUDERDALE FL
33309-3750
US

V. Phone/Fax

Practice location:
  • Phone: 954-522-3355
  • Fax: 954-522-9590
Mailing address:
  • Phone: 954-522-3355
  • Fax: 954-522-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101778
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: