Provider Demographics
NPI:1801898341
Name:D'ANTUONO, DOMINICK A (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINICK
Middle Name:A
Last Name:D'ANTUONO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 606
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017
Mailing Address - Country:US
Mailing Address - Phone:213-483-1055
Mailing Address - Fax:213-483-1418
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 606
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017
Practice Address - Country:US
Practice Address - Phone:213-483-1055
Practice Address - Fax:213-483-1418
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR65225Medicare UPIN