Provider Demographics
NPI:1891319646
Name:TRAN, MARY THI (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THI
Last Name:TRAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6230 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-4541
Mailing Address - Country:US
Mailing Address - Phone:510-303-5595
Mailing Address - Fax:
Practice Address - Street 1:100 PARK PL STE 200
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4416
Practice Address - Country:US
Practice Address - Phone:510-303-5595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty