Provider Demographics
NPI:1922845528
Name:DEMATTIES, DOMINIQUE (AGNP)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DEMATTIES
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1892
Mailing Address - Country:US
Mailing Address - Phone:315-471-8388
Mailing Address - Fax:
Practice Address - Street 1:1000 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1892
Practice Address - Country:US
Practice Address - Phone:315-471-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311889363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology