Provider Demographics
NPI:1225697329
Name:CAPORUSSO, DOMINIQUE (PA-C)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CAPORUSSO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DOMINIQUE
Other - Middle Name:
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 CASAGRANDE ST
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-4023
Mailing Address - Country:US
Mailing Address - Phone:859-512-7050
Mailing Address - Fax:
Practice Address - Street 1:650 SPRUCEWOOD LN
Practice Address - Street 2:
Practice Address - City:ERLANGER
Practice Address - State:KY
Practice Address - Zip Code:41018-1062
Practice Address - Country:US
Practice Address - Phone:859-282-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC835363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical