Provider Demographics
NPI:1457660391
Name:DOMINGO, MICHELLE MAE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MAE
Last Name:DOMINGO
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 1:4075 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6146
Mailing Address - Country:US
Mailing Address - Phone:323-566-4111
Mailing Address - Fax:
Practice Address - Street 1:4075 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6146
Practice Address - Country:US
Practice Address - Phone:323-566-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52600363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical