Provider Demographics
NPI:1205200094
Name:TRAN, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TRAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MISTLETOE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4049
Mailing Address - Country:US
Mailing Address - Phone:817-878-5333
Mailing Address - Fax:
Practice Address - Street 1:1900 MISTLETOE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4049
Practice Address - Country:US
Practice Address - Phone:817-878-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1205200094Medicaid