Provider Demographics
NPI:1043028335
Name:LOPEZ, MICAILA (PA-C)
Entity type:Individual
Prefix:
First Name:MICAILA
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 1:10777 NALL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1330
Mailing Address - Country:US
Mailing Address - Phone:913-642-0200
Mailing Address - Fax:913-563-6699
Practice Address - Street 1:10777 NALL AVE STE 300
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66211-1330
Practice Address - Country:US
Practice Address - Phone:913-642-0200
Practice Address - Fax:913-563-6699
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-03052363AS0400X
MO2025010280363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical