Provider Demographics
NPI:1326477134
Name:LOPEZ, JUAN JOSE (MSN, RN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:JOSE
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MSN, RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5336 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2944
Mailing Address - Country:US
Mailing Address - Phone:623-419-2799
Mailing Address - Fax:602-548-7649
Practice Address - Street 1:5336 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2944
Practice Address - Country:US
Practice Address - Phone:623-419-2799
Practice Address - Fax:602-548-7649
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN172210163W00000X
AZAP7356363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ004494Medicaid
AZ004494Medicaid