Basic Information
Provider Information | |||||||||
NPI: | 1710134226 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRAN | ||||||||
FirstName: | THAI LAN | ||||||||
MiddleName: | NGUYEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 35 E GLENARM ST | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911053418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267684415 | ||||||||
FaxNumber: | 6264030321 | ||||||||
Practice Location | |||||||||
Address1: | 1441 CONSTITUTION BLVD | ||||||||
Address2: |   | ||||||||
City: | SALINAS | ||||||||
State: | CA | ||||||||
PostalCode: | 939063100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267684415 | ||||||||
FaxNumber: | 6264030321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2008 | ||||||||
LastUpdateDate: | 04/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A111671 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | A111671 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | A111671 | CA | Y |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
ID Information
ID | Type | State | Issuer | Description | 1578023792 | 05 | CA |   | MEDICAID |