Provider Demographics
NPI:1609657741
Name:DOMAGUING, JARED
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:DOMAGUING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BEN LOMOND
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-3940
Mailing Address - Country:US
Mailing Address - Phone:510-690-7357
Mailing Address - Fax:
Practice Address - Street 1:450 N WIGET LN
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2408
Practice Address - Country:US
Practice Address - Phone:510-690-7357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027588363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner