Healthcare Provider Details

I. General information

NPI: 1124031174
Provider Name (Legal Business Name): GUERDA DOMINIQUE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIE GUERDA DOMINIQUE PA

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NEVINS ST STE 306
BRIGHTON MA
02135-3514
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4505
  • Fax:
Mailing address:
  • Phone: 617-414-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001307
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA200001547
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC01930
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA8505
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: