Provider Demographics
NPI:1235606518
Name:DOMINGUEZ, MARIAH PAZ (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:PAZ
Last Name:DOMINGUEZ
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 1:103 S JACKSON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2211
Mailing Address - Country:US
Mailing Address - Phone:517-212-9000
Mailing Address - Fax:
Practice Address - Street 1:770 KENMOOR AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8602
Practice Address - Country:US
Practice Address - Phone:616-272-3533
Practice Address - Fax:616-259-4839
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine