Provider Demographics
NPI:1407627342
Name:LOPEZ, MASON TAYLOR (FNP-C)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:TAYLOR
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 LAWNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1231
Mailing Address - Country:US
Mailing Address - Phone:616-835-6626
Mailing Address - Fax:
Practice Address - Street 1:5320 RUSCHE DR NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9551
Practice Address - Country:US
Practice Address - Phone:800-442-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704341520363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily