Basic Information
| Provider Information | |||||||||
| NPI: | 1649268913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMINGUEZ | ||||||||
| FirstName: | GUADALUPE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5701 W CHARLESTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891461217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023123444 | ||||||||
| FaxNumber: | 7023123510 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 CIVIC CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890307143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028779514 | ||||||||
| FaxNumber: | 7023123510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA849 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1649268913 | 05 | NV | MEDICAID |