Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of August 10, 2026.
NPIDirectory

Justin Domenico

Individual provider Physician Assistant · NPI 1053960690

Justin Domenico is a Physician Assistant in Wynnewood, Pennsylvania. Qualified in 2019, 7 years ago. Practices with University of Penn-Medical Group, a 3,401-clinician group and accepts Medicare assignment.

Years since qualifying
7
In the registry since
2019
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Practice location Address checks out

100 E Lancaster Ave
Wynnewood, PA 19096-3450
Phone: (484) 476-2000
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Pin is approximate — placed at the ZIP-code centre, not the exact door.

Specialties & licences

Physician Assistant (primary) Taxonomy 363A00000X

Record details

NPI number1053960690
Entity typeIndividual (Type 1)
GenderMale
Sole proprietorNo
NPI enumeratedSeptember 6, 2019
Last updated in NPPESSeptember 6, 2019
Mailing address631 Villa Rd, Drexel Hill, PA 19026-1435

Medicare enrollment

From the CMS Doctors & Clinicians file — this clinician is enrolled in Medicare.

Medicare specialtyPHYSICIAN ASSISTANT
Medical schoolOTHER
Graduated 2019 (7 years in practice)
Group practice University Of Penn-Medical Group — 3401 clinicians
Accepts Medicare assignment Yes — accepts the Medicare-approved amount

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