Provider Demographics
NPI:1023207461
Name:MILLER-LOPEZ, MARNI L (PA)
Entity Type:Individual
Prefix:
First Name:MARNI
Middle Name:L
Last Name:MILLER-LOPEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARNI
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10470 OLD PLACERVILLE ROAD, SUITE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:855-771-0335
Mailing Address - Fax:916-503-7513
Practice Address - Street 1:2800 L ST STE 501
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5616
Practice Address - Country:US
Practice Address - Phone:916-454-6850
Practice Address - Fax:916-454-6852
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3721363AM0700X, 363AS0400X
CAPA54367363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ307788Medicaid
AZZ118820Medicare PIN