Basic Information
| Provider Information | |||||||||
| NPI: | 1386079424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | CARLOS | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 HEPBURN RD | ||||||||
| Address2: | APT 5M | ||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070122231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014782205 | ||||||||
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| Practice Location | |||||||||
| Address1: | 622 W 168TH ST | ||||||||
| Address2: | AIM CLINIC VC2 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100323720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123056262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 08/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 337744 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.