Provider Demographics
NPI:1407325731
Name:DOMINGUEZ, TABATHA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TABATHA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 752
Mailing Address - Street 2:
Mailing Address - City:HONDO
Mailing Address - State:TX
Mailing Address - Zip Code:78861-0752
Mailing Address - Country:US
Mailing Address - Phone:830-931-5008
Mailing Address - Fax:
Practice Address - Street 1:3200 AVENUE E
Practice Address - Street 2:
Practice Address - City:HONDO
Practice Address - State:TX
Practice Address - Zip Code:78861-3525
Practice Address - Country:US
Practice Address - Phone:830-426-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP139722Medicaid