Healthcare Provider Details

I. General information

NPI: 1841917226
Provider Name (Legal Business Name): ANTHONY M KANGEA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 06/12/2023
Certification Date: 06/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11020 OPTUM CIR
EDEN PRAIRIE MN
55344-2503
US

IV. Provider business mailing address

1020 OLD DENBIGH BLVD
NEWPORT NEWS VA
23602-2017
US

V. Phone/Fax

Practice location:
  • Phone: 757-604-1881
  • Fax:
Mailing address:
  • Phone: 757-875-2050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024184760
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: