Provider Demographics
NPI:1336625870
Name:LOPEZ, CHRISTIAN
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name: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 1:2936 AVENUE W APT 6D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5323
Mailing Address - Country:US
Mailing Address - Phone:718-877-2883
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040
Practice Address - Country:US
Practice Address - Phone:718-470-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY627234163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse