Provider Demographics
NPI:1063186963
Name:LOGUIDICE, DOMINIQUE JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JEAN
Last Name:LOGUIDICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W ESSEX ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07607-1023
Mailing Address - Country:US
Mailing Address - Phone:201-289-5551
Mailing Address - Fax:
Practice Address - Street 1:113 W ESSEX ST STE 204
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1023
Practice Address - Country:US
Practice Address - Phone:201-289-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00631600363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical