Provider Demographics
NPI:1245919448
Name:DOMORACKI, JACOB (CRNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:DOMORACKI
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-1710
Mailing Address - Country:US
Mailing Address - Phone:216-882-7044
Mailing Address - Fax:
Practice Address - Street 1:232 W 25TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16544-0001
Practice Address - Country:US
Practice Address - Phone:814-452-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN670780163WC0200X
PASP028313363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN670780OtherREGISTERED NURSE LICENSE
PASP028313OtherCERTIFIED REGISTERED NURSE PRACTITIONER - ADULT-GERONTOLOGY ACUTE CARE