Provider Demographics
NPI:1386739639
Name:LOPEZ, HEIDI ROTH (CRNA)
Entity type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:ROTH
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4908 REGAL CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5025
Mailing Address - Country:US
Mailing Address - Phone:916-300-8852
Mailing Address - Fax:916-663-6758
Practice Address - Street 1:812 4TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5667
Practice Address - Country:US
Practice Address - Phone:530-741-3937
Practice Address - Fax:530-741-2109
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2184367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5839834OtherMEDI-CAL /EDS
CACGP170273OtherDHS / CCS
CAZZZ19682ZMedicare ID - Type Unspecified
CA5839834OtherMEDI-CAL /EDS