Healthcare Provider Details

I. General information

NPI: 1265143531
Provider Name (Legal Business Name): DOMINIQUE PETERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE CAYTON

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 KEARNEY ST
FREMONT CA
94538-2299
US

IV. Provider business mailing address

430 ALPINE HEIGHTS RD
ALPINE CA
91901-2872
US

V. Phone/Fax

Practice location:
  • Phone: 510-490-1222
  • Fax:
Mailing address:
  • Phone: 661-330-7032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: