Healthcare Provider Details

I. General information

NPI: 1427483130
Provider Name (Legal Business Name): ANTONIO J LOPEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-7209
US

IV. Provider business mailing address

2495 SHREVEPORT HWY
PINEVILLE LA
71360-4044
US

V. Phone/Fax

Practice location:
  • Phone: 377-706-3145
  • Fax:
Mailing address:
  • Phone: 337-706-3415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200674
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: