MEDICARE: NIDIA LOPEZ PA & COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1104595875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIDIA LOPEZ PA & COMPANY

Provider Business Mailing Address
First Line	:	300 BEECH TREE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79928-7483
Country	:	US
Telephone Number	:	915-490-2402
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 BEECH TREE DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79928-7483
Country	:	US
Telephone Number	:	915-490-2402
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NIDIA LOPEZ
Credential	:
Telephone Number	:	915-490-2402

Provider Enumeration Date	:	09/07/2021
Last Update Date	:	09/07/2021

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