Provider Demographics
NPI:1366856304
Name:LOPEZ, MARCO OLIVER DUGAN (DNP, FNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:MARCO OLIVER
Middle Name:DUGAN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:DNP, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 FELL ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-5144
Mailing Address - Country:US
Mailing Address - Phone:415-861-0828
Mailing Address - Fax:
Practice Address - Street 1:52 DORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-3828
Practice Address - Country:US
Practice Address - Phone:415-861-0828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA716471163W00000X, 163WP2201X
CA2013001613163WP0808X
CA95000854363LF0000X, 363L00000X
CA2015009739363LP0808X
CA95000845363LP0808X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA75207OtherCALIFORNIA BOARD OF REGISTERED NURSING PHN#
CA95000854OtherCALIFORNIA BOARD OF REGISTERED NURSING NP FURNISHING#
CA95000854OtherCALIFORNIA BOARD OF REGISTERED NURSING NP#
CA716471OtherCALIFORNIA BOARD OF REGISTERED NURSING RN#