Provider Demographics
NPI:1376714139
Name:DOMINIQUE, TYESHA
Entity Type:Individual
Prefix:MRS
First Name:TYESHA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 E 94TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5604
Mailing Address - Country:US
Mailing Address - Phone:212-423-3000
Mailing Address - Fax:212-423-2920
Practice Address - Street 1:312 E 94TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-5604
Practice Address - Country:US
Practice Address - Phone:212-423-3000
Practice Address - Fax:212-423-2920
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant