Provider Demographics
NPI:1063924181
Name:LOPEZ DE LATCHUM, KIARA MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:KIARA
Middle Name:MICHELLE
Last Name:LOPEZ DE LATCHUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIARA
Other - Middle Name:
Other - Last Name:AGUAYO LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1420 LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19607-1540
Mailing Address - Country:US
Mailing Address - Phone:484-467-7391
Mailing Address - Fax:
Practice Address - Street 1:4301 5TH STREET HWY STE 101
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:PA
Practice Address - Zip Code:19560-1739
Practice Address - Country:US
Practice Address - Phone:610-208-8800
Practice Address - Fax:610-898-1336
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2024-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059530363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical