MEDICARE: BROOKE ELIZABETH LOPEZ MMS, 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	12304844-1206	UT

General Provider Information

NPI Number	:	1912549379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ELIZABETH LOPEZ MMS, PA-C

Provider Business Mailing Address
First Line	:	10290 N NORTH COUNTY BLVD STE 200
Second Line	:
City	:	HIGHLAND
State	:	UT
Zip	:	84003-8973
Country	:	US
Telephone Number	:	801-899-3391
Fax Number	:

Provider Business Practice Location Address
First Line	:	10290 N NORTH COUNTY BLVD STE 200
Second Line	:
City	:	HIGHLAND
State	:	UT
Zip	:	84003-8973
Country	:	US
Telephone Number	:	801-899-3391
Fax Number	:

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

Provider Enumeration Date	:	10/16/2019
Last Update Date	:	12/08/2021

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