Provider Demographics
NPI:1043037468
Name:DOMINGUEZ, KAYLA (PA)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2693 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1624
Mailing Address - Country:US
Mailing Address - Phone:409-832-8862
Mailing Address - Fax:409-832-1664
Practice Address - Street 1:2693 NORTH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1624
Practice Address - Country:US
Practice Address - Phone:409-832-8862
Practice Address - Fax:409-832-1664
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18313363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical