1558971853 NPI number — CHARLEEN BAO TRAN PHAN-CAO PHARMD

Table of content: CHARLEEN BAO TRAN PHAN-CAO PHARMD (NPI 1558971853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558971853 NPI number — CHARLEEN BAO TRAN PHAN-CAO PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHAN-CAO
Provider First Name:
CHARLEEN
Provider Middle Name:
BAO TRAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PHAN
Provider Other First Name:
CHARLEEN
Provider Other Middle Name:
BAO TRAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558971853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5820 S 80TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68516-3813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-617-5956
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4808 O ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLN
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68510-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-467-1134
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2020

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: 183500000X , with the licence number:  14967 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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