Healthcare Provider Details

I. General information

NPI: 1699841288
Provider Name (Legal Business Name): DANIEL WILLIAM LOPEZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ATWELL RD
COOPERSTOWN NY
13326-1301
US

IV. Provider business mailing address

10859 US HIGHWAY 98 W PERSONNAL MAILBOX 134
MIRAMAR BEACH FL
32550-7869
US

V. Phone/Fax

Practice location:
  • Phone: 607-547-6924
  • Fax:
Mailing address:
  • Phone: 207-232-5814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number391082
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: