Provider Demographics
NPI:1689772469
Name:DOMINGUEZ, DAVID ANTHONY (APRN)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ANTHONY
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-5210
Mailing Address - Country:US
Mailing Address - Phone:785-762-5250
Mailing Address - Fax:785-762-2144
Practice Address - Street 1:814 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-5210
Practice Address - Country:US
Practice Address - Phone:785-762-5250
Practice Address - Fax:785-762-2144
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC112063363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005013Medicaid
NC6005013Medicaid