Provider Demographics
NPI:1295919280
Name:PHAN, TRANG H (PA-C)
Entity type:Individual
Prefix:
First Name:TRANG
Middle Name:H
Last Name:PHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 MILAN AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-4427
Mailing Address - Country:US
Mailing Address - Phone:616-204-1094
Mailing Address - Fax:
Practice Address - Street 1:1003 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-1234
Practice Address - Country:US
Practice Address - Phone:989-892-7722
Practice Address - Fax:989-892-7455
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004098363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN97410001Medicare PIN
MIQ23091Medicare UPIN