MEDICARE: KRYSTAL LEANN 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	PA11688	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1146937	OTHER		NCCPA

General Provider Information

NPI Number	:	1972019909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL LEANN LOPEZ PA-C

Provider Business Mailing Address
First Line	:	4607 TIMBERGLEN RD APT 1934
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-5256
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4607 TIMBERGLEN RD APT 1934
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75287-5256
Country	:	US
Telephone Number	:	214-934-5735
Fax Number	:

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

Provider Enumeration Date	:	12/28/2017
Last Update Date	:	12/28/2017

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