1326477134 NPI number — MR. JUAN JOSE LOPEZ MSN, RN, FNP-C

Table of content: MR. JUAN JOSE LOPEZ MSN, RN, FNP-C (NPI 1326477134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326477134 NPI number — MR. JUAN JOSE LOPEZ MSN, RN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
JUAN
Provider Middle Name:
JOSE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326477134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5336 N 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85015-2944
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-419-2799
Provider Business Mailing Address Fax Number:
602-548-7649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5336 N 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85015-2944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-419-2799
Provider Business Practice Location Address Fax Number:
602-548-7649
Provider Enumeration Date:
11/02/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN172210 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP7356 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004494 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".