Provider Demographics
NPI:1063254910
Name:DOMINGO, SAMUEL (MSN, FNP)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:DOMINGO
Suffix:
Gender:M
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 GIBSON DR APT 2626
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5416
Mailing Address - Country:US
Mailing Address - Phone:657-272-9586
Mailing Address - Fax:
Practice Address - Street 1:1528 EUREKA RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3047
Practice Address - Country:US
Practice Address - Phone:916-772-5325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty