Provider Demographics
NPI:1952907669
Name:LOPEZ TELLERIA, PAVEL MIGUEL (APRN)
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:MIGUEL
Last Name:LOPEZ TELLERIA
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9317 NW 114TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4269
Mailing Address - Country:US
Mailing Address - Phone:786-333-6845
Mailing Address - Fax:
Practice Address - Street 1:9317 NW 114TH LN
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-4269
Practice Address - Country:US
Practice Address - Phone:786-333-6845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty