Healthcare Provider Details

I. General information

NPI: 1063254910
Provider Name (Legal Business Name): SAMUEL DOMINGO MSN, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOAG DR
NEWPORT BEACH CA
92663-4162
US

IV. Provider business mailing address

2119 PENDIO
IRVINE CA
92620-1760
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-5691
  • Fax: 949-764-4242
Mailing address:
  • Phone: 562-540-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95029993
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: