Healthcare Provider Details

I. General information

NPI: 1891925848
Provider Name (Legal Business Name): G MICHAEL LOPEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 07/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MILLS AVE STE 300
LAS VEGAS NM
87701-4169
US

IV. Provider business mailing address

105 MILLS AVE # 300
LAS VEGAS NM
87701
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-9311
  • Fax: 505-425-9047
Mailing address:
  • Phone: 505-425-9311
  • Fax: 505-425-9047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberNM81-770
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number92PA09
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR53421
License Number StateNM

VIII. Authorized Official

Name: DR. G MICHAEL LOPEZ
Title or Position: OWNER
Credential: MD
Phone: 505-425-9311