Provider Demographics
NPI:1942735881
Name:ANCONA, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ANCONA
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 1:1865 ROUTE 70 E
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-2005
Mailing Address - Country:US
Mailing Address - Phone:856-427-4336
Mailing Address - Fax:
Practice Address - Street 1:1865 ROUTE 70 E
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-2005
Practice Address - Country:US
Practice Address - Phone:856-427-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471967207Q00000X
390200000X
NJ25MA10905700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty