Provider Demographics
NPI:1598203051
Name:KOONS, DOMINIQUE CHRISTINA (PA)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:CHRISTINA
Last Name:KOONS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 COUNTRY BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-1114
Mailing Address - Country:US
Mailing Address - Phone:609-364-6826
Mailing Address - Fax:
Practice Address - Street 1:1505 W SHERMAN AVE STE 112
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7059
Practice Address - Country:US
Practice Address - Phone:856-641-7920
Practice Address - Fax:856-641-7915
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-05
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00421800364SX0200X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology