Provider Demographics
NPI:1558094581
Name:TRAC, TOAN TAN (DPT)
Entity Type:Individual
Prefix:
First Name:TOAN
Middle Name:TAN
Last Name:TRAC
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 SAFEHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4057
Mailing Address - Country:US
Mailing Address - Phone:404-512-8966
Mailing Address - Fax:
Practice Address - Street 1:9409K OLD BURKE LAKE RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3127
Practice Address - Country:US
Practice Address - Phone:703-425-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015866225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist