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General NPI Number Information
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NPI Number | 1497788327
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Entity Type | Organization
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Legal Business Name | PANDA BEAR PEDIATRICS
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Dates
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Enumeration Date | 07/07/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 555 SOUTH SECOND AVENUE BUILDING B, SUITE 200
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City | COLLEGEVILLE
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State | PA
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Zip | 19426-2854
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Country | US
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Telephone | 610-409-8050
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Fax | 610-409-8075
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Provider Business Mailing Address
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Address Line | 102 SHETLAND WAY
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City | COLLEGEVILLE
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State | PA
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Zip | 19426-2854
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Country | US
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Telephone | 610-409-8050
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Fax | 610-409-8075
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Authorized Official
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Title or Position | PHYSICIAN/MANAGING MEMBER
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Name | DR. LARISSA F DOMINY
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Credential | D.O.
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Telephone | 610-409-8050
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | OS-009162L
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License Number State | PA
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