Healthcare Provider Details

I. General information

NPI: 1881068252
Provider Name (Legal Business Name): ROBERT LOPEZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2015
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 707-423-3735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number770385
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: