Healthcare Provider Details

I. General information

NPI: 1679036925
Provider Name (Legal Business Name): ERICA LEE DOMOGAUER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERICA LEE ROSENTHAL PA-C

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 03/07/2023
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 HIGHWAY 9 E
LITTLE RIVER SC
29566-7826
US

IV. Provider business mailing address

PO BOX 3439
NORTH MYRTLE BEACH SC
29582-0439
US

V. Phone/Fax

Practice location:
  • Phone: 843-497-5929
  • Fax: 866-778-9612
Mailing address:
  • Phone: 843-839-6379
  • Fax: 843-399-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTL3218
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: