=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730348087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC NELSON LOPEZ JR. PHYSICIAN ASSISTANT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | BLDG 50, FARENHOLT AVE
-----------------------------------------------------
City | AGANA HEIGHTS
-----------------------------------------------------
State | GU
-----------------------------------------------------
Zip | 96910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 671-339-3168
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 788 HOLIDAY TOWER CONDO, ROUTE 4, APT 707
-----------------------------------------------------
City | SINAJANA
-----------------------------------------------------
State | GU
-----------------------------------------------------
Zip | 96910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-480-4685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA56031
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------