Provider Demographics
NPI:1124031174
Name:DOMINIQUE, GUERDA (PA)
Entity type:Individual
Prefix:
First Name:GUERDA
Middle Name:
Last Name:DOMINIQUE
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:GUERDA
Other - Last Name:DOMINIQUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:960 MASSACHUSETTS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2690
Mailing Address - Country:US
Mailing Address - Phone:617-414-4505
Mailing Address - Fax:
Practice Address - Street 1:11 NEVINS ST STE 306
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3514
Practice Address - Country:US
Practice Address - Phone:617-414-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001307363A00000X
DCPA200001547363AS0400X
MDC01930363A00000X
MAPA8505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP15083Medicare UPIN
MDH33000QQMedicare PIN