Basic Information
| Provider Information | |||||||||
| NPI: | 1174981492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | ELEONORA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 GLEN COVE AVE | ||||||||
| Address2: | NORTH COAST MEDICAL GROUP | ||||||||
| City: | SEA CLIFF | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115791455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166761742 | ||||||||
| FaxNumber: | 5166769662 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 GLEN COVE AVE | ||||||||
| Address2: | NORTH COAST MEDICAL GROUP | ||||||||
| City: | SEA CLIFF | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115791455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166761742 | ||||||||
| FaxNumber: | 5166769662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2016 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 30 307218 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | 30 307218 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.