Provider Demographics
NPI:1548871387
Name:ANCONA, DOMINIC NICHOLAS GIOVANNI (PA)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:NICHOLAS GIOVANNI
Last Name:ANCONA
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 1:1111 RANCH FLS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1989
Mailing Address - Country:US
Mailing Address - Phone:210-517-2378
Mailing Address - Fax:
Practice Address - Street 1:3333 RESEARCH PLZ
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235-5154
Practice Address - Country:US
Practice Address - Phone:210-517-2378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X390200000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program