Healthcare Provider Details

I. General information

NPI: 1861269664
Provider Name (Legal Business Name): MIGUEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 01/13/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 MANHATTAN SQ
HAMPTON VA
23666-5843
US

IV. Provider business mailing address

7101 HUNTERS CHASE
NORFOLK VA
23518-4449
US

V. Phone/Fax

Practice location:
  • Phone: 757-838-8030
  • Fax:
Mailing address:
  • Phone: 210-364-9886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: