Healthcare Provider Details

I. General information

NPI: 1588800502
Provider Name (Legal Business Name): YUNIEL LOPEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2008
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15955 SW 96TH ST STE 401
MIAMI FL
33196-1273
US

IV. Provider business mailing address

PO BOX 100905
ATLANTA GA
30384-0905
US

V. Phone/Fax

Practice location:
  • Phone: 786-467-3430
  • Fax: 786-533-9695
Mailing address:
  • Phone: 786-467-3430
  • Fax: 786-533-9695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9104754
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: