Provider Demographics
NPI:1144289133
Name:LOPEZ, JULIO B (PA-C)
Entity type:Individual
Prefix:MR
First Name:JULIO
Middle Name:B
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4450 S TIFFANY DR
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3241
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-844-1013
Practice Address - Street 1:315 S W C OWENS AVE
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-3637
Practice Address - Country:US
Practice Address - Phone:863-983-7813
Practice Address - Fax:863-983-9604
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290257500Medicaid
FLAU519ZMedicare PIN