Provider Demographics
NPI:1679036925
Name:DOMOGAUER, ERICA LEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:LEE
Last Name:DOMOGAUER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ERICA
Other - Middle Name:LEE
Other - Last Name:ROSENTHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3439
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-0439
Mailing Address - Country:US
Mailing Address - Phone:843-839-6379
Mailing Address - Fax:843-399-0123
Practice Address - Street 1:3361 HIGHWAY 9 E
Practice Address - Street 2:
Practice Address - City:LITTLE RIVER
Practice Address - State:SC
Practice Address - Zip Code:29566-7826
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:866-778-9612
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL3218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1679036925Medicaid
SC3167PAMedicaid
SC3167PAMedicaid