Provider Demographics
NPI:1760914386
Name:DOMINIQUE, PATRICIA (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE.,
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 MASSACHUSETTS AVE
Practice Address - Street 2:CROSSTOWN 2ND FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2605
Practice Address - Country:US
Practice Address - Phone:617-414-4376
Practice Address - Fax:617-414-4676
Is Sole Proprietor?:No
Enumeration Date:2017-04-02
Last Update Date:2017-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN268854363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110122168AMedicaid