Provider Demographics
NPI:1871565796
Name:LOPEZ, JOB PORTILLO (FNP)
Entity type:Individual
Prefix:MR
First Name:JOB
Middle Name:PORTILLO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
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Mailing Address - Street 1:80834 GENTLE BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-8478
Mailing Address - Country:US
Mailing Address - Phone:760-578-5612
Mailing Address - Fax:760-863-5885
Practice Address - Street 1:81767 DR CARREON BLVD STE 102
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5598
Practice Address - Country:US
Practice Address - Phone:760-863-5355
Practice Address - Fax:760-863-5885
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2023-08-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CANPF9223 RN643640363LF0000X
CA9223363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18496ZMedicare ID - Type UnspecifiedMEDICARE NUMBER