MEDICARE: DEYANIRA 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	363A00000X	Physician Assistant	PA03193	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA03193	OTHER	TX	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1841316403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEYANIRA LOPEZ PA-C

Provider Business Mailing Address
First Line	:	2821 MICHAEL ANGELO
Second Line	:	SUITE 400
City	:	EDINBURG
State	:	TX
Zip	:	78539-1404
Country	:	US
Telephone Number	:	956-683-7900
Fax Number	:	956-683-9910

Provider Business Practice Location Address
First Line	:	5326 E US HIGHWAY 83
Second Line	:	SUITE A-5
City	:	RIO GRANDE CITY
State	:	TX
Zip	:	78582-9409
Country	:	US
Telephone Number	:	956-488-8820
Fax Number	:	956-488-8853

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	12/02/2010

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