Healthcare Provider Details

I. General information

NPI: 1528578515
Provider Name (Legal Business Name): BRET L. LOPEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 N 300 W STE 201
PROVO UT
84604-6124
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-1200
  • Fax:
Mailing address:
  • Phone: 801-357-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14204269-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: