Provider Demographics
NPI:1770612731
Name:TRAHAN, JODY G (RN, CNOR)
Entity type:Individual
Prefix:MR
First Name:JODY
Middle Name:G
Last Name:TRAHAN
Suffix:
Gender:M
Credentials:RN, CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17424 W GRAND PKWY S # 122
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2564
Mailing Address - Country:US
Mailing Address - Phone:409-673-1128
Mailing Address - Fax:866-360-3539
Practice Address - Street 1:17424 W GRAND PKWY S # 122
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2564
Practice Address - Country:US
Practice Address - Phone:409-673-1128
Practice Address - Fax:866-360-3539
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX597248163W00000X, 163WR0006X, 246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No163W00000XNursing Service ProvidersRegistered Nurse
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX20-5874534OtherTAX ID#