Provider Demographics
NPI:1205843323
Name:TRAN, QUYEN NGOC (CRNA)
Entity Type:Individual
Prefix:
First Name:QUYEN
Middle Name:NGOC
Last Name:TRAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ATTN: MARIA MITCHELL, PO BOX 5635
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407
Mailing Address - Country:US
Mailing Address - Phone:812-337-5003
Mailing Address - Fax:812-337-5010
Practice Address - Street 1:2920 MCINTYRE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-4221
Practice Address - Country:US
Practice Address - Phone:812-337-5003
Practice Address - Fax:812-337-5010
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28147932A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000489968OtherSIA ANTHEM
IN546430VMedicare ID - Type UnspecifiedSIA