1043216179 NPI number — CAROL TRAN PA

Table of content: CAROL TRAN PA (NPI 1043216179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043216179 NPI number — CAROL TRAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRAN
Provider First Name:
CAROL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043216179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6500 JEFFERSON ST NE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-3486
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-843-8758
Provider Business Mailing Address Fax Number:
505-843-8759

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3619 PAESANOS PKWY
Provider Second Line Business Practice Location Address:
STE 212
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78231-1253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-690-5599
Provider Business Practice Location Address Fax Number:
210-690-5595
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA04560 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00298578 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 840878 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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