Basic Information
| Provider Information | |||||||||
| NPI: | 1629231980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | LIDICE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 261 W 32ND ST | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330125317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055280447 | ||||||||
| FaxNumber: | 3054663223 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 NW 12TH AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331361003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055456685 | ||||||||
| FaxNumber: | 3055656687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9104530 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.