Healthcare Provider Details

I. General information

NPI: 1407111834
Provider Name (Legal Business Name): PRESTON ERIC LOPEZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LILLY RD NE STE 100
OLYMPIA WA
98506-5117
US

IV. Provider business mailing address

PO BOX 368
OLYMPIA WA
98507-0368
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4211
  • Fax:
Mailing address:
  • Phone: 360-455-5144
  • Fax: 360-491-7536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: