Provider Demographics
NPI:1548772460
Name:WARD, DOMENIQUE DICELLO (PA-C)
Entity Type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:DICELLO
Last Name:WARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DOMENIQUE
Other - Middle Name:DARA
Other - Last Name:DICELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5028 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15102-2024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 BROOKS LN STE 170
Practice Address - Street 2:
Practice Address - City:JEFFERSON HILLS
Practice Address - State:PA
Practice Address - Zip Code:15025-3759
Practice Address - Country:US
Practice Address - Phone:412-469-7110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059553363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical