Provider Demographics
NPI:1730113101
Name:LOPEZ, DANIEL C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:C
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 LARCHWOOD PL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6276 RIVER CREST DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0783
Practice Address - Country:US
Practice Address - Phone:951-413-0964
Practice Address - Fax:951-653-5161
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14440363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA144400Medicaid
CAGR0086790Medicaid
CAGR0086790Medicaid
CA0PA144400Medicare UPIN
CA0PA144400Medicaid