Healthcare Provider Details

I. General information

NPI: 1316302490
Provider Name (Legal Business Name): JUAN JOSE LOPEZ EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 REID STREET, ATTN: MCHJ-CLQ-C MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-1000
US

IV. Provider business mailing address

9040 REID STREET, ATTN: MCHJ-CLQ-C MADIGAN ARMY MEDICAL CENTER
TACOMA WA
98431-1000
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1110
  • Fax: 877-874-1031
Mailing address:
  • Phone: 253-968-1110
  • Fax: 877-874-1031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberE2059605
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95377472
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: