Provider Demographics
NPI:1720739568
Name:LOPEZ, RICARDO (PA)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:550 W BASELINE RD STE 102-435
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6040
Mailing Address - Country:US
Mailing Address - Phone:323-487-3202
Mailing Address - Fax:
Practice Address - Street 1:550 W BASELINE RD STE 102-435
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6040
Practice Address - Country:US
Practice Address - Phone:323-487-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9526363A00000X, 363A00000X
AZ9525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant