Provider Demographics
NPI:1760793012
Name:DOMBECK, NATHAN R (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:R
Last Name:DOMBECK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MINERAL POINT AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2940
Mailing Address - Country:US
Mailing Address - Phone:608-756-6049
Mailing Address - Fax:608-756-6521
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:608-756-6049
Practice Address - Fax:608-756-6521
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2568023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIDOMBENATOtherMERCYCARE INSURANCE
WI1760793012OtherBCBSWI
WI1760793012Medicaid
WI541760874Medicare PIN