1679036925 NPI number — MRS. ERICA LEE DOMOGAUER PA-C

Table of content: MRS. ERICA LEE DOMOGAUER PA-C (NPI 1679036925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679036925 NPI number — MRS. ERICA LEE DOMOGAUER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMOGAUER
Provider First Name:
ERICA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROSENTHAL
Provider Other First Name:
ERICA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679036925
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3439
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29582-0439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-839-6379
Provider Business Mailing Address Fax Number:
843-399-0123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3361 HIGHWAY 9 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE RIVER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29566-7826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-497-5929
Provider Business Practice Location Address Fax Number:
866-778-9612
Provider Enumeration Date:
04/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  TL3218 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1679036925 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3167PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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