Provider Demographics
NPI:1619043312
Name:LOPEZ, CARMEN VICTORIA (CRNA)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:VICTORIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10501 WILSHIRE BLVD #2002
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024
Mailing Address - Country:US
Mailing Address - Phone:310-738-0306
Mailing Address - Fax:
Practice Address - Street 1:450 N ROXBURY DR
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4232
Practice Address - Country:US
Practice Address - Phone:310-453-8911
Practice Address - Fax:310-453-2519
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2410367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2410OtherNURSE ANESTHETIST
CA375695OtherSTATE LICENSE NURSE
CANA0024100OtherBLUE SHIELD OF CALIFORNIA
CAWNA2410BMedicare ID - Type UnspecifiedPPIN