Provider Demographics
NPI:1427483130
Name:LOPEZ, ANTONIO J (PA)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:J
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 1:2495 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:337-706-3415
Mailing Address - Fax:
Practice Address - Street 1:3149 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-7209
Practice Address - Country:US
Practice Address - Phone:377-706-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
LAPA.200674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical