Provider Demographics
NPI:1124031174
Name:DOMINIQUE, GUERDA (PA)
Entity Type:Individual
Prefix:
First Name:GUERDA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:GUERDA
Other - Last Name:DOMINIQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 37174
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3174
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:900 23RD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-2342
Practice Address - Country:US
Practice Address - Phone:202-715-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001307363A00000X
MDC01930363A00000X
DCPA200001547363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP15083Medicare UPIN
MDH33000QQMedicare PIN