MEDICARE: MR. NOE MANUEL LOPEZ JR. 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	PA20105	CA

General Provider Information

NPI Number	:	1629210075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NOE MANUEL LOPEZ JR. PA-C

Provider Business Mailing Address
First Line	:	1695 N SUNRISE WAY
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-3701
Country	:	US
Telephone Number	:	760-323-2118
Fax Number	:	760-416-1651

Provider Business Practice Location Address
First Line	:	510 S ALVARADO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-2904
Country	:	US
Telephone Number	:	213-483-3600
Fax Number	:	213-483-4555

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

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	06/28/2018

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