Basic Information
| Provider Information | |||||||||
| NPI: | 1467091827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOMIBAO | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | DALATEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9360 MONONA DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193033681 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 340 4TH AVE STE 14 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919103813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193033681 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2020 | ||||||||
| LastUpdateDate: | 01/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP95013019 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.