Provider Demographics
NPI:1871623876
Name:LOPEZ, MARTIN JOSE (PA)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:JOSE
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 1:6207 COWLITZ LN
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-6760
Mailing Address - Country:US
Mailing Address - Phone:509-547-2607
Mailing Address - Fax:
Practice Address - Street 1:5304 N ROAD 68
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-9189
Practice Address - Country:US
Practice Address - Phone:509-543-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOA10000117363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical