Provider Demographics
NPI:1831713429
Name:LOPEZ, GUERRERO IVAN
Entity type:Individual
Prefix:
First Name:GUERRERO
Middle Name:IVAN
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:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:SMITH CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:66967-0349
Mailing Address - Country:US
Mailing Address - Phone:785-262-6834
Mailing Address - Fax:785-282-6331
Practice Address - Street 1:921 E HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:SMITH CENTER
Practice Address - State:KS
Practice Address - Zip Code:66967-9582
Practice Address - Country:US
Practice Address - Phone:785-282-6834
Practice Address - Fax:785-282-6331
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-30
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS15-02397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program