Provider Demographics
NPI:1750373213
Name:LOPEZ, ERIC J (PA-C)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:LOPEZ
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 1:605 SOUTH CONROE MEDICAL DRIVE
Mailing Address - Street 2:STE 100
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2928
Mailing Address - Country:US
Mailing Address - Phone:936-523-5236
Mailing Address - Fax:
Practice Address - Street 1:605 S CONROE MEDICAL DR
Practice Address - Street 2:STE 100
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-4722
Practice Address - Country:US
Practice Address - Phone:936-523-5236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA735363A00000X
TXPA05322363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100505898Medicaid
NV100505898Medicaid