MEDICARE: MISS MANNETTE MALDONADO LOPEZ MD

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	363AM0700X	Medical Physician Assistant	2795PA	PR

General Provider Information

NPI Number	:	1154272375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MANNETTE MALDONADO LOPEZ MD

Provider Business Mailing Address
First Line	:	VILLA RICA AD4 CALLE EDMEE
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	VILLA RICA AD4 CALLE EDMEE
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00959
Country	:	US
Telephone Number	:	787-299-0991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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