Provider Demographics
NPI:1104952209
Name:LOPEZ, JORGE LUIS (PA)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:LUIS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:EVANS ARMY COMMUNITY HOSPITAL (EACH) USA MEDDAC
Mailing Address - Street 2:1650 COCHRANE CIRCLE, ATTN CREDENTIALS OFFICE
Mailing Address - City:COLORADO SPINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-7844
Mailing Address - Fax:
Practice Address - Street 1:1650 COCHRANE CIR
Practice Address - Street 2:ATTN CREDENTIALS OFFICE
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4603
Practice Address - Country:US
Practice Address - Phone:719-526-7844
Practice Address - Fax:719-526-7984
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant