Provider Demographics
NPI:1306953385
Name:LOPEZ-FAGIN, LEA (FNP)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:LOPEZ-FAGIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13409 NW MILITARY HWY
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SHAVANO PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1800
Mailing Address - Country:US
Mailing Address - Phone:210-479-3297
Mailing Address - Fax:210-479-3295
Practice Address - Street 1:13409 NW MILITARY HWY
Practice Address - Street 2:SUITE 302
Practice Address - City:SHAVANO PARK
Practice Address - State:TX
Practice Address - Zip Code:78231-1800
Practice Address - Country:US
Practice Address - Phone:210-479-3297
Practice Address - Fax:210-479-3295
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX428422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142765002Medicaid