Basic Information
| Provider Information | |||||||||
| NPI: | 1952332694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 820 N CHELAN AVE | ||||||||
| Address2: | |||||||||
| City: | WENATCHEE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988012028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096638711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD00037649 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 132077 | 01 | WA | L&I | OTHER | 1952332694 | 05 | WA | MEDICAID | P01256553 | 01 | WA | RR MEDICARE | OTHER | 315809 | 01 | WA | L&I POST 7/21/13 | OTHER |