Basic Information
| Provider Information | |||||||||
| NPI: | 1902342967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOMZALSKI | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 TAHOE CIR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273320123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197213694 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1638 OWEN DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106154000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2017 | ||||||||
| LastUpdateDate: | 01/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-06970 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.