MEDICARE: CHRISTOPHER OMAR DOMINGUEZ CRUZ

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	363LF0000X	Family Nurse Practitioner	11046877	FL

General Provider Information

NPI Number	:	1629910351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER OMAR DOMINGUEZ CRUZ

Provider Business Mailing Address
First Line	:	24 UTRILLO PL
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5901
Country	:	US
Telephone Number	:	386-347-9873
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 UTRILLO PL
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5901
Country	:	US
Telephone Number	:	386-347-9873
Fax Number	:

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

Provider Enumeration Date	:	04/09/2026
Last Update Date	:	04/16/2026

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