Provider Demographics
NPI:1689784530
Name:DOMINGUEZ, KATHLEEN H (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:H
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:760-753-7143
Mailing Address - Fax:760-753-7114
Practice Address - Street 1:477 N EL CAMINO REAL STE B105
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1330
Practice Address - Country:US
Practice Address - Phone:760-753-7143
Practice Address - Fax:760-753-7114
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17714208000000X
CAPA17714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics