Provider Demographics
NPI:1730962952
Name:ANTONOVA, ANNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:ANTONOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2263 PLUM AVE
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-3538
Mailing Address - Country:US
Mailing Address - Phone:267-752-5511
Mailing Address - Fax:
Practice Address - Street 1:6501 HARBISON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2912
Practice Address - Country:US
Practice Address - Phone:215-333-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP028340363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty