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General NPI Number Information
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NPI Number | 1457010001
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Entity Type | Individual
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Provider Name | DOMANTE BERULYTE PA-C
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Gender | Female
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Dates
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Enumeration Date | 12/10/2021
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Last Update Date | 02/10/2023
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Provider Practice Location Address
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Address Line | 15720 WINCHESTER BLVD
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City | LOS GATOS
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State | CA
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Zip | 95030-3337
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Country | US
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Telephone | 408-730-6160
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Fax |
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Provider Business Mailing Address
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Address Line | 325 DISTEL CIR
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City | LOS ALTOS
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State | CA
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Zip | 94022-1408
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA60194
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License Number State | CA
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