Provider Demographics
NPI:1538456090
Name:LOPEZ, FALLON NASSIEM AGAHI
Entity type:Individual
Prefix:MS
First Name:FALLON
Middle Name:NASSIEM AGAHI
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:FALLON
Other - Middle Name:NASSIEM
Other - Last Name:AGAHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3105 CEDAR RAVINE RD
Mailing Address - Street 2:STE 201
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6561
Mailing Address - Country:US
Mailing Address - Phone:530-626-1602
Mailing Address - Fax:
Practice Address - Street 1:3301 C ST
Practice Address - Street 2:BLDG 550
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-3300
Practice Address - Country:US
Practice Address - Phone:916-556-3164
Practice Address - Fax:916-733-5920
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant