MEDICARE: MICHELLE MAE DOMINGO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	52600	CA

General Provider Information

NPI Number	:	1457660391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MAE DOMINGO

Provider Business Mailing Address
First Line	:	4075 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-6146
Country	:	US
Telephone Number	:	323-566-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	4075 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-6146
Country	:	US
Telephone Number	:	323-566-4111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2010
Last Update Date	:	06/23/2015

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Directions to “ MICHELLE MAE DOMINGO ” Practice Location

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