Healthcare Provider Details

I. General information

NPI: 1700579380
Provider Name (Legal Business Name): GABRIEL ALFONSO LOPEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 S CAGE BLVD
PHARR TX
78577-6716
US

IV. Provider business mailing address

2404 S CAGE BLVD
PHARR TX
78577-6716
US

V. Phone/Fax

Practice location:
  • Phone: 956-702-6462
  • Fax:
Mailing address:
  • Phone: 956-702-6462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20015
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: