Healthcare Provider Details

I. General information

NPI: 1013927110
Provider Name (Legal Business Name): MICHAEL LONG TRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 HOEN AVE
SANTA ROSA CA
95405
US

IV. Provider business mailing address

4704 HOEN AVE
SANTA ROSA CA
95405
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-7979
  • Fax: 707-546-7667
Mailing address:
  • Phone: 707-546-7979
  • Fax: 707-546-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG085353
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG085353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: