Provider Demographics
NPI:1306345533
Name:DOMINGUEZ, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W CLEVELAND AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-4940
Mailing Address - Country:US
Mailing Address - Phone:702-207-0842
Mailing Address - Fax:
Practice Address - Street 1:308 W CLEVELAND AVE APT 8
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4940
Practice Address - Country:US
Practice Address - Phone:702-630-7527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2102188250OtherDRIVER LICENSE