MEDICARE: GINA RAMONA LOPEZ PA-C

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	PA 21382	CA

General Provider Information

NPI Number	:	1306140678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA RAMONA LOPEZ PA-C

Provider Business Mailing Address
First Line	:	8540 S SEPULVEDA BLVD STE 1100
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3819
Country	:	US
Telephone Number	:	310-568-8938
Fax Number	:

Provider Business Practice Location Address
First Line	:	8540 S SEPULVEDA BLVD STE 1100
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-3819
Country	:	US
Telephone Number	:	310-568-8938
Fax Number	:

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

Provider Enumeration Date	:	12/30/2010
Last Update Date	:	12/30/2010

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