Provider Demographics
NPI:1629421102
Name:LOPEZ MARTINEZ, ADITAIM (NP)
Entity Type:Individual
Prefix:
First Name:ADITAIM
Middle Name:
Last Name:LOPEZ MARTINEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ADITAIM
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1354 KILBY LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-7166
Mailing Address - Country:US
Mailing Address - Phone:760-845-0363
Mailing Address - Fax:
Practice Address - Street 1:13522 NEWPORT AVE
Practice Address - Street 2:UNIT 200
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3707
Practice Address - Country:US
Practice Address - Phone:800-658-5877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004455363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner