Provider Demographics
NPI:1164770889
Name:DOMINGO, ADRIAN S
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:S
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 ROSECRANS STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3886
Mailing Address - Country:US
Mailing Address - Phone:619-692-8232
Mailing Address - Fax:
Practice Address - Street 1:3853 ROSECRANS STREET
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3886
Practice Address - Country:US
Practice Address - Phone:619-692-8232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN242682164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse