Basic Information
| Provider Information | |||||||||
| NPI: | 1356936868 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | BIANCA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22137 W MESQUITE DR | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853265538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028146812 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13677 W MCDOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853952635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238821500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2021 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 8679 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.