Provider Demographics
NPI:1124246673
Name:LOPERENA, ELIGIO JR (PA)
Entity type:Individual
Prefix:
First Name:ELIGIO
Middle Name:
Last Name:LOPERENA
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11329 SW 77TH WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE BUTLER
Mailing Address - State:FL
Mailing Address - Zip Code:32054-9667
Mailing Address - Country:US
Mailing Address - Phone:386-496-2598
Mailing Address - Fax:
Practice Address - Street 1:368 NE FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3088
Practice Address - Country:US
Practice Address - Phone:386-754-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant