Provider Demographics
NPI:1225887524
Name:DOMINGUEZ, JUAN CARLOS (FNP)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 OCEAN AVE APT 3H
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4728
Mailing Address - Country:US
Mailing Address - Phone:917-600-2816
Mailing Address - Fax:
Practice Address - Street 1:9033 ELMHURST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7935
Practice Address - Country:US
Practice Address - Phone:718-457-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-17
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354416363LF0000X
NY809914163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice