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General NPI Number Information
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NPI Number | 1891925848
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Entity Type | Organization
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Legal Business Name | G MICHAEL LOPEZ
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Dates
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Enumeration Date | 07/23/2009
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Last Update Date | 07/23/2009
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Provider Practice Location Address
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Address Line | 105 MILLS AVE STE 300
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City | LAS VEGAS
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State | NM
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Zip | 87701-4169
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Country | US
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Telephone | 505-425-9311
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Fax | 505-425-9047
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Provider Business Mailing Address
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Address Line | 105 MILLS AVE # 300
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City | LAS VEGAS
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State | NM
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Zip | 87701
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Country | US
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Telephone | 505-425-9311
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Fax | 505-425-9047
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Authorized Official
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Title or Position | OWNER
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Name | DR. G MICHAEL LOPEZ
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Credential | MD
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Telephone | 505-425-9311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 92PA09
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | R53421
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | NM81-770
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License Number State | NM
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