Provider Demographics
NPI:1740615236
Name:ANCONA, BRENT A (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:A
Last Name:ANCONA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E NICOLLET BLVD
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5714
Mailing Address - Country:US
Mailing Address - Phone:952-892-2000
Mailing Address - Fax:
Practice Address - Street 1:201 E NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5714
Practice Address - Country:US
Practice Address - Phone:952-892-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO3578207R00000X
ND14220207R00000X, 208M00000X
MN70545207R00000X
TXS3352208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist