Provider Demographics
NPI:1861478216
Name:DOMINICK, GERALD F (PA C)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:F
Last Name:DOMINICK
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:PO BOX 41115
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23541-1115
Mailing Address - Country:US
Mailing Address - Phone:757-466-0089
Mailing Address - Fax:757-466-8017
Practice Address - Street 1:5544 GREENWICH RD
Practice Address - Street 2:STE.200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6563
Practice Address - Country:US
Practice Address - Phone:757-466-0089
Practice Address - Fax:757-466-8017
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA219354363A00000X
VA0110000927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA139178OtherBCBS
VA10005129POtherSENTARA
VA10005129POtherOPTIMA
VAP00318486OtherRR MEDICARE
VA1861478216Medicaid
VA009140M13Medicare PIN
VAP00318486OtherRR MEDICARE