Provider Demographics
NPI:1003213919
Name:DOMZALSKI, SEAN D (PA-C)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:D
Last Name:DOMZALSKI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 S PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTICOKE
Mailing Address - State:PA
Mailing Address - Zip Code:18634-2449
Mailing Address - Country:US
Mailing Address - Phone:570-417-5402
Mailing Address - Fax:
Practice Address - Street 1:150 MUNDY STREET
Practice Address - Street 2:MAC IV BUILDING
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-824-0930
Practice Address - Fax:570-824-7755
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057321363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50130489OtherCAPITAL BLUE CROSS
PA50130489OtherCAPITAL BLUE CROSS