Provider Demographics
NPI:1982320966
Name:DOMINGO, JOHN PAOLO ESTANISALO (APRN)
Entity Type:Individual
Prefix:MR
First Name:JOHN PAOLO
Middle Name:ESTANISALO
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 S PHYLLIS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-0977
Mailing Address - Country:US
Mailing Address - Phone:702-460-0195
Mailing Address - Fax:
Practice Address - Street 1:5216 BOULDER HWY STE 105
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-6075
Practice Address - Country:US
Practice Address - Phone:702-547-6764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV816856363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily