Healthcare Provider Details

I. General information

NPI: 1871251090
Provider Name (Legal Business Name): JUSTIN DOMURAT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2021
Last Update Date: 12/05/2021
Certification Date: 12/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 GREENBELT RD
GREENBELT MD
20770-3402
US

IV. Provider business mailing address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

V. Phone/Fax

Practice location:
  • Phone: 301-982-5437
  • Fax:
Mailing address:
  • Phone: 516-869-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number61214691
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: