Provider Demographics
NPI:1326584822
Name:TRAHAN, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:TRAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-9037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:CARRIERE
Practice Address - State:MS
Practice Address - Zip Code:39426-9037
Practice Address - Country:US
Practice Address - Phone:601-799-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901907363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily