Provider Demographics
NPI:1407619455
Name:LOPEZ, JEFFERSON GONZALO (PA)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:GONZALO
Last Name:LOPEZ
Suffix:
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 1:225 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4539
Mailing Address - Country:US
Mailing Address - Phone:631-665-1600
Mailing Address - Fax:
Practice Address - Street 1:225 EASTVIEW DR
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4539
Practice Address - Country:US
Practice Address - Phone:631-665-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant