Provider Demographics
NPI:1972195527
Name:TRAN, THAI BAO (NP)
Entity Type:Individual
Prefix:
First Name:THAI
Middle Name:BAO
Last Name:TRAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:920 DOUG WHITE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4181
Mailing Address - Country:US
Mailing Address - Phone:843-497-6348
Mailing Address - Fax:843-497-6351
Practice Address - Street 1:920 DOUG WHITE DR STE 210
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4181
Practice Address - Country:US
Practice Address - Phone:843-497-6348
Practice Address - Fax:843-497-6351
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5014070363L00000X, 363LA2200X
SC26043363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology