Provider Demographics
NPI:1649268913
Name:DOMINGUEZ, GUADALUPE R (PAC)
Entity type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:R
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 W CHARLESTON BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1217
Mailing Address - Country:US
Mailing Address - Phone:702-312-3444
Mailing Address - Fax:702-312-3510
Practice Address - Street 1:1905 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-7143
Practice Address - Country:US
Practice Address - Phone:702-877-9514
Practice Address - Fax:702-312-3510
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1649268913Medicaid
NV100505575Medicaid
NV1649268913Medicaid
100505577OtherMEDICAID 31
39658Medicare ID - Type Unspecified