Provider Demographics
NPI:1831747971
Name:DOMINGUEZ, MIRIAM NOELLE (PA-C)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:NOELLE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10750 COLUMBIA PIKE UNIT 401A
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4402
Mailing Address - Country:US
Mailing Address - Phone:301-593-6072
Mailing Address - Fax:
Practice Address - Street 1:10750 COLUMBIA PIKE UNIT 401A
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4402
Practice Address - Country:US
Practice Address - Phone:301-593-6072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-02
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07137363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1158970OtherNCCPA
MDC07137OtherMARYLAND BOARD OF PHYSICIANS