Healthcare Provider Details

I. General information

NPI: 1104723238
Provider Name (Legal Business Name): GABRIEL LOPEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2026
Last Update Date: 10/22/2026
Certification Date: 10/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W GUAVA ST STE 206
LADY LAKE FL
32159-1702
US

IV. Provider business mailing address

201 W GUAVA ST STE 206
LADY LAKE FL
32159-1702
US

V. Phone/Fax

Practice location:
  • Phone: 352-430-0473
  • Fax:
Mailing address:
  • Phone: 352-205-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA32478
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: