Basic Information
| Provider Information | |||||||||
| NPI: | 1609042878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | EDDY | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2735 W 52ND ST APT 103 | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330164771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7862903277 | ||||||||
| FaxNumber: | 3057574465 | ||||||||
| Practice Location | |||||||||
| Address1: | 4175 W 20TH AVE | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330125874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058250300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11004646 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.