Provider Demographics
NPI:1073710117
Name:DOMENICK, LAUREL (PAC)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:DOMENICK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1033 WEST GERMANTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19403-3998
Mailing Address - Country:US
Mailing Address - Phone:610-539-8500
Mailing Address - Fax:610-539-0910
Practice Address - Street 1:1033 W GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-3905
Practice Address - Country:US
Practice Address - Phone:610-539-8500
Practice Address - Fax:610-539-0910
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001501L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant