Provider Demographics
NPI:1336891258
Name:LOPEZ, YACKSON
Entity Type:Individual
Prefix:
First Name:YACKSON
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 1:1412 SAYLOR WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-1510
Mailing Address - Country:US
Mailing Address - Phone:347-928-7498
Mailing Address - Fax:
Practice Address - Street 1:1412 SAYLOR WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-1510
Practice Address - Country:US
Practice Address - Phone:347-928-7498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant