Provider Demographics
NPI:1538668066
Name:DOMINIC, GAETEN J (RNFA)
Entity Type:Individual
Prefix:
First Name:GAETEN
Middle Name:J
Last Name:DOMINIC
Suffix:
Gender:M
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3138 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-5439
Mailing Address - Country:US
Mailing Address - Phone:215-817-0076
Mailing Address - Fax:
Practice Address - Street 1:3138 S 18TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-5439
Practice Address - Country:US
Practice Address - Phone:215-817-0076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN253608L163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant