Provider Demographics
NPI:1942662739
Name:LOPEZ, LAURA MARQUEZ (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARQUEZ
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7979 N SHADELAND AVE STE 310
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2042
Practice Address - Country:US
Practice Address - Phone:765-621-3780
Practice Address - Fax:765-621-3088
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002039A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005047Medicaid
INP01678957OtherMEDICARE RR
IN300005047Medicaid