Provider Demographics
NPI:1700573722
Name:DOMINGO, MA PORTIA BERNADETTE GUCE (DO)
Entity type:Individual
Prefix:
First Name:MA PORTIA BERNADETTE
Middle Name:GUCE
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PHOEBE
Other - Middle Name:
Other - Last Name:DOMINGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:819 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4112
Practice Address - Country:US
Practice Address - Phone:360-814-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL61440780390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program