Healthcare Provider Details

I. General information

NPI: 1245540145
Provider Name (Legal Business Name): MICHAEL JOE LAO LOPEZ C.R.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2010
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 FLOYD ST STE 304
SARASOTA FL
34239-2932
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-261-0500
  • Fax: 941-261-0505
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11013114
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR162164
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: