Provider Demographics
NPI:1487744306
Name:MALDONADO, JOSE LOPEZ (PA-C)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LOPEZ
Last Name:MALDONADO
Suffix:
Gender:M
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 1:2604 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9417
Mailing Address - Country:US
Mailing Address - Phone:919-580-0004
Mailing Address - Fax:919-580-9224
Practice Address - Street 1:2604 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9417
Practice Address - Country:US
Practice Address - Phone:919-580-0004
Practice Address - Fax:919-580-9224
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC102234OtherLICENSE
2326720Medicare UPIN
S57777Medicare UPIN
2767242Medicare PIN
2767242AMedicare PIN