Healthcare Provider Details

I. General information

NPI: 1982880795
Provider Name (Legal Business Name): CATHERINE DOMINGO OMS RN, PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 12/08/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 COMMERCENTER E STE 100
SAN BERNARDINO CA
92408-3423
US

IV. Provider business mailing address

1150 S MEADOW LN APT 9
COLTON CA
92324-6471
US

V. Phone/Fax

Practice location:
  • Phone: 909-478-7776
  • Fax:
Mailing address:
  • Phone: 909-709-7657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number19561
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: