Basic Information
| Provider Information | |||||||||
| NPI: | 1043216179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRAN | ||||||||
| FirstName: | CAROL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 JEFFERSON ST NE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871093486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058438758 | ||||||||
| FaxNumber: | 5058438759 | ||||||||
| Practice Location | |||||||||
| Address1: | 3619 PAESANOS PKWY | ||||||||
| Address2: | STE 212 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782311253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106905599 | ||||||||
| FaxNumber: | 2106905595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 11/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA04560 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00298578 | 01 | RAILROAD MEDICARE | OTHER | 840878 | 01 | TX | BCBS | OTHER |