Basic Information
| Provider Information | |||||||||
| NPI: | 1568427912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMIN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310 | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032470310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035243211 | ||||||||
| FaxNumber: | 6035277038 | ||||||||
| Practice Location | |||||||||
| Address1: | 96 HIGH STREET | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035249197 | ||||||||
| FaxNumber: | 6035249142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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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 | 207V00000X | 6193 | NH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 020346032 | 01 | TAX ID | OTHER | 0105602YONH01 | 01 | NH | ANTHEM | OTHER | 00000575 | 05 | NH | MEDICAID | 81166895 | 05 | NH | MEDICAID |