Provider Demographics
NPI:1154883486
Name:DOMINGUEZ, CHARLIE (FNP)
Entity type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1605 EL PASEO RD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-6010
Mailing Address - Country:US
Mailing Address - Phone:575-523-5400
Mailing Address - Fax:
Practice Address - Street 1:1521 JOE BATTLE BLVD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-0922
Practice Address - Country:US
Practice Address - Phone:915-790-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM557338363LF0000X
TXAP140823363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily