Provider Demographics
NPI:1346215159
Name:DOMINGUEZ, AMY C (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:C
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7321 STANGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-5951
Mailing Address - Country:US
Mailing Address - Phone:702-645-1933
Mailing Address - Fax:
Practice Address - Street 1:653 NORTHTOWN CENTER DR IVE
Practice Address - Street 2:SUITE 514
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144
Practice Address - Country:US
Practice Address - Phone:702-243-2689
Practice Address - Fax:702-243-2632
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVAPN000781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P69630Medicare UPIN