Provider Demographics
NPI:1386307569
Name:NINO-LOPEZ, JUAN-DAVID (NP)
Entity type:Individual
Prefix:
First Name:JUAN-DAVID
Middle Name:
Last Name:NINO-LOPEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 FRISBIE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5831
Mailing Address - Country:US
Mailing Address - Phone:530-219-0352
Mailing Address - Fax:
Practice Address - Street 1:154 FRISBIE ST APT 1
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5831
Practice Address - Country:US
Practice Address - Phone:530-219-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018808363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty