Provider Demographics
NPI:1952737116
Name:DOMINGO, MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DOMINGO
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 1:575 STATE ROUTE 28 STE 2108
Mailing Address - Street 2:
Mailing Address - City:RARITAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08869-1354
Mailing Address - Country:US
Mailing Address - Phone:973-295-6335
Mailing Address - Fax:862-204-3456
Practice Address - Street 1:575 STATE ROUTE 28 STE 2108
Practice Address - Street 2:
Practice Address - City:RARITAN
Practice Address - State:NJ
Practice Address - Zip Code:08869-1354
Practice Address - Country:US
Practice Address - Phone:973-295-6335
Practice Address - Fax:862-204-3456
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY016993363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical