Provider Demographics
NPI:1700500600
Name:MANSAT, DOMINADOR PERALTA JR (FNP-C)
Entity Type:Individual
Prefix:
First Name:DOMINADOR
Middle Name:PERALTA
Last Name:MANSAT
Suffix:JR
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9415 RETREAT PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-9200
Mailing Address - Country:US
Mailing Address - Phone:909-348-3067
Mailing Address - Fax:877-615-1555
Practice Address - Street 1:1910 S ARCHIBALD AVE STE D
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8503
Practice Address - Country:US
Practice Address - Phone:909-348-2556
Practice Address - Fax:877-615-1555
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022872363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily