Healthcare Provider Details

I. General information

NPI: 1073505202
Provider Name (Legal Business Name): JOHN D. LOPEZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 GRANDE DR
PENSACOLA FL
32504-8965
US

IV. Provider business mailing address

4901 GRANDE DR
PENSACOLA FL
32504-8965
US

V. Phone/Fax

Practice location:
  • Phone: 850-477-7042
  • Fax: 850-474-9060
Mailing address:
  • Phone: 850-477-7042
  • Fax: 850-474-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP1726152
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number109696
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: