Healthcare Provider Details

I. General information

NPI: 1407344302
Provider Name (Legal Business Name): DANIEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 08/08/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16811 SE MCGILLIVRAY BLVD
VANCOUVER WA
98683-3404
US

IV. Provider business mailing address

40918 N PARKER CT
PHOENIX AZ
85086-2712
US

V. Phone/Fax

Practice location:
  • Phone: 360-735-8100
  • Fax: 360-253-1781
Mailing address:
  • Phone: 480-735-8934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61159118
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: