Basic Information
| Provider Information | |||||||||
| NPI: | 1770549750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | NIDIA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722340819 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 GRANDVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799025113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155446750 | ||||||||
| FaxNumber: | 9155324259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA04792 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 809N07 | 01 | TX | BCBS | OTHER | P00889868 | 01 | TX | RAILROAD MEDICARE | OTHER | 204427301 | 05 | TX | MEDICAID | 205265608 | 05 | TX | MEDICAID | 830N22 | 01 | TX | BCBS | OTHER |