Provider Demographics
NPI:1134769292
Name:LOPEZ, STACEY (PA-C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SW JOHNSON AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5834
Mailing Address - Country:US
Mailing Address - Phone:817-718-3571
Mailing Address - Fax:817-447-8100
Practice Address - Street 1:621 SW JOHNSON AVE STE C
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5834
Practice Address - Country:US
Practice Address - Phone:817-766-7421
Practice Address - Fax:817-447-8100
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant