Provider Demographics
NPI:1134627797
Name:TRAN, STEPHANIE B
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:B
Last Name:TRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47149 BUSE RD BLDG 1370
Mailing Address - Street 2:
Mailing Address - City:PATUXENT RVR
Mailing Address - State:MD
Mailing Address - Zip Code:20670-1540
Mailing Address - Country:US
Mailing Address - Phone:904-627-0353
Mailing Address - Fax:
Practice Address - Street 1:47149 BUSE RD BLDG 1370
Practice Address - Street 2:
Practice Address - City:PATUXENT RVR
Practice Address - State:MD
Practice Address - Zip Code:20670-1540
Practice Address - Country:US
Practice Address - Phone:904-627-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X, 390200000X
VA0101267489208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program