Provider Demographics
NPI:1528611498
Name:LOPEZ, SUSAN ANGELICA (SA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANGELICA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OAK ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-3824
Mailing Address - Country:US
Mailing Address - Phone:631-880-1387
Mailing Address - Fax:
Practice Address - Street 1:31 OAK ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-3824
Practice Address - Country:US
Practice Address - Phone:631-880-1387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19-277246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant