Basic Information
| Provider Information | |||||||||
| NPI: | 1528525409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0677214951 | ||||||||
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| Address1: | 1120 15TH ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309121000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067214951 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2019 | ||||||||
| LastUpdateDate: | 04/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 11945 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.