Provider Demographics
NPI:1972668580
Name:LOPEZ, FREDERICK PORRAL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:PORRAL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 DARTMOUTH PLACE
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510
Mailing Address - Country:US
Mailing Address - Phone:215-771-3968
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DRIVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-651-3884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3351367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered