Provider Demographics
NPI:1376928028
Name:TRAN, THAO (PA-C)
Entity type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:TRAN
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 1:4755 OGLETOWN STANTON RD STE 1070
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-733-1663
Mailing Address - Fax:302-733-4533
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 1070
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-1663
Practice Address - Fax:302-733-4533
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1127892363AM0700X
DEC5-0012062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015508900Medicaid
FL015508900Medicaid