Provider Demographics
NPI:1265059307
Name:DOMINGUEZ, AMANDA ANTOINETTE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANTOINETTE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ANTOINETTE
Other - Last Name:JENSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:6584 PINNACLE CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1272
Mailing Address - Country:US
Mailing Address - Phone:310-270-3716
Mailing Address - Fax:
Practice Address - Street 1:1240 S WESTLAKE BLVD STE 205
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-1992
Practice Address - Country:US
Practice Address - Phone:805-495-0551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-05
Last Update Date:2020-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17489363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical