Healthcare Provider Details

I. General information

NPI: 1164264099
Provider Name (Legal Business Name): PEDRO ANTONIO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 01/27/2025
Certification Date:
Deactivation Date: 01/16/2025
Reactivation Date: 01/27/2025

III. Provider practice location address

MSC 10 5550 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC 10 5550 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-4661
  • Fax: 505-272-0475
Mailing address:
  • Phone: 505-272-4661
  • Fax: 505-272-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: