=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265143531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIQUE PETERSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2022
-----------------------------------------------------
Last Update Date | 10/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 KEARNEY ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-2299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-490-1222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 ALPINE HEIGHTS RD
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91901-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-330-7032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA61911
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------