Provider Demographics
NPI:1902668833
Name:DOMINGO, ARDEE BUTAC (FNP-C)
Entity Type:Individual
Prefix:
First Name:ARDEE
Middle Name:BUTAC
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 VALLEY VIEW TER
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-4088
Mailing Address - Country:US
Mailing Address - Phone:949-510-8934
Mailing Address - Fax:
Practice Address - Street 1:27001 MOULTON PKWY
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92656-3600
Practice Address - Country:US
Practice Address - Phone:949-600-1907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027092363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner