Provider Demographics
NPI:1336936764
Name:LOPEZ, KRISTINA (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:100 N EDINBURGH DR STE 200
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4125
Practice Address - Country:US
Practice Address - Phone:407-645-5565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9120181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant