Individual
SEAN D DOMZALSKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
150 MUNDY STREET, MAC IV BUILDING, WILKES-BARRE, PA 18702
(570) 824-0930
(570) 824-7755
Mailing address
243 S PROSPECT ST, NANTICOKE, PA 18634-2449
(570) 417-5402
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
MA057321
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50130489
CAPITAL BLUE CROSS
PA
Enumeration date
11/21/2014
Last updated
09/21/2015
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