Provider Demographics
NPI:1851186761
Name:SHORT, DOMINIQUE MARIE (PA)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:MARIE
Last Name:SHORT
Suffix:
Gender:
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:169 UNIVERSITY MNR E
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 UNIVERSITY MANOR APART
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2363
Practice Address - Country:US
Practice Address - Phone:717-531-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-11
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant