Provider Demographics
NPI:1184196719
Name:DOMINGUEZ, LAURA LIDIA (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LIDIA
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 SAGE CREST DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-8004
Mailing Address - Country:US
Mailing Address - Phone:559-310-4506
Mailing Address - Fax:
Practice Address - Street 1:361 TOWN CTR W
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-5076
Practice Address - Country:US
Practice Address - Phone:805-922-6581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010540363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner