Provider Demographics
NPI:1225431992
Name:SISTO, DOMINIQUE (PA-C)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:SISTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24719 LONG VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HIDDEN HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 615
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1801
Practice Address - Country:US
Practice Address - Phone:818-905-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant