Basic Information
| Provider Information | |||||||||
| NPI: | 1689772469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 CAROLINE AVE | ||||||||
| Address2: | |||||||||
| City: | JUNCTION CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664415210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857625250 | ||||||||
| FaxNumber: | 7857622144 | ||||||||
| Practice Location | |||||||||
| Address1: | 814 CAROLINE AVE | ||||||||
| Address2: | |||||||||
| City: | JUNCTION CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664415210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857625250 | ||||||||
| FaxNumber: | 7857622144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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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 | 363LP0808X | 112063 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 6005013 | 05 | NC | MEDICAID |