Provider Demographics
NPI:1902418429
Name:PEREZ LOPEZ, DAMIAN
Entity Type:Individual
Prefix:
First Name:DAMIAN
Middle Name:
Last Name:PEREZ LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 E SAHARA AVE APT E210
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-2779
Mailing Address - Country:US
Mailing Address - Phone:702-717-1600
Mailing Address - Fax:
Practice Address - Street 1:511 E SAHARA AVE APT E210
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-2779
Practice Address - Country:US
Practice Address - Phone:702-717-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2106341914Medicaid