Provider Demographics
NPI:1972208874
Name:AMEGASHITSI, DOMINIC DOTSE
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:DOTSE
Last Name:AMEGASHITSI
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 1:4546 ARROWHEAD DR APT 7
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54703-6218
Mailing Address - Country:US
Mailing Address - Phone:651-285-3818
Mailing Address - Fax:
Practice Address - Street 1:4546 ARROWHEAD DR APT 74546
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-6217
Practice Address - Country:US
Practice Address - Phone:651-285-3818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver