Healthcare Provider Details

I. General information

NPI: 1396248852
Provider Name (Legal Business Name): JEREMIAH EUGENE TRAN AG-ACNPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. JEREMIAH CONWAY

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W BETHANY HOME RD
PHOENIX AZ
85015-2443
US

IV. Provider business mailing address

6115 W NORTH LN
GLENDALE AZ
85302-1246
US

V. Phone/Fax

Practice location:
  • Phone: 602-249-0212
  • Fax:
Mailing address:
  • Phone: 602-888-2662
  • Fax: 602-887-5756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN172376
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP11167
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: