=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285468082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAR ROSA LOPEZ FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2024
-----------------------------------------------------
Last Update Date | 10/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 W DR MARTIN LUTHER KING JR BLVD STE A
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33603-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-822-5363
-----------------------------------------------------
Fax | 727-895-3313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8000 SW 117TH AVE STE 205
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33183-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-751-6380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11035112
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------