Provider Demographics
NPI:1790464659
Name:TRAN, MARY (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:TRAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CLUB LN
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-7957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 CLUB LN
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-7957
Practice Address - Country:US
Practice Address - Phone:724-459-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant