Provider Demographics
NPI:1659453454
Name:DOMNINE, MIKHAIL V (PA)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:V
Last Name:DOMNINE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 MIDDLEBROOK RD STE 410
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-5281
Mailing Address - Country:US
Mailing Address - Phone:301-652-8847
Mailing Address - Fax:
Practice Address - Street 1:12850 MIDDLEBROOK RD STE 410
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-5281
Practice Address - Country:US
Practice Address - Phone:301-652-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052604363A00000X
NC001001114363A00000X
MDC0009827363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2687OtherEVOLUTIONS HEALTHCARE SYSTEMS
NC164XJOtherBCBSNC
NC7790899OtherAETNA
NC164XJOtherBCBSNC