Provider Demographics
NPI:1740599844
Name:DOMINIQUE, NADYA MAREE (MD)
Entity Type:Individual
Prefix:
First Name:NADYA
Middle Name:MAREE
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 HOWARD AVENUE
Mailing Address - Street 2:SUITE F2
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601
Mailing Address - Country:US
Mailing Address - Phone:814-889-2701
Mailing Address - Fax:814-889-7864
Practice Address - Street 1:501 HOWARD AVENUE
Practice Address - Street 2:SUITE F2
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601
Practice Address - Country:US
Practice Address - Phone:814-889-2701
Practice Address - Fax:814-889-7864
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT196732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RES0000Medicare UPIN