Provider Demographics
NPI:1891441119
Name:DOMINICK, AMANDA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:DOMINICK
Suffix:
Gender:F
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 1:3100 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3239
Mailing Address - Country:US
Mailing Address - Phone:530-526-2665
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3239
Practice Address - Country:US
Practice Address - Phone:530-526-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant