Provider Demographics
NPI:1194824136
Name:DOMINO, LEROY ANTHONY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:ANTHONY
Last Name:DOMINO
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859
Mailing Address - Street 2:DEPT 710
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-7773
Mailing Address - Country:US
Mailing Address - Phone:409-747-6240
Mailing Address - Fax:
Practice Address - Street 1:200 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4204
Practice Address - Country:US
Practice Address - Phone:832-632-6372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX663623367500000X
TXAP114089367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177072901Medicaid