Provider Demographics
NPI:1093492621
Name:DOMACHOWSKE, SARA PAULINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:PAULINE
Last Name:DOMACHOWSKE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2895 STATE ROUTE 48
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6524
Mailing Address - Country:US
Mailing Address - Phone:315-532-4590
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1899
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF352332-01363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner