Provider Demographics
NPI:1487657029
Name:KOH, DOMINIC E B (CPNP, ANP-C)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:E B
Last Name:KOH
Suffix:
Gender:M
Credentials:CPNP, ANP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2571 ROCHELLE AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4941
Mailing Address - Country:US
Mailing Address - Phone:626-303-3950
Mailing Address - Fax:
Practice Address - Street 1:1530 HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5516
Practice Address - Country:US
Practice Address - Phone:323-644-3880
Practice Address - Fax:323-644-3892
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN476192, NPF 8506363LA2200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS98883Medicare UPIN
CAWNP8506AMedicare ID - Type Unspecified