Healthcare Provider Details

I. General information

NPI: 1992066302
Provider Name (Legal Business Name): ANDY QUOC TRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18102 IRVINE BLVD SUITE 207
TUSTIN CA
92780-3402
US

IV. Provider business mailing address

18102 IRVINE BLVD
TUSTIN CA
92780-3402
US

V. Phone/Fax

Practice location:
  • Phone: 714-505-2966
  • Fax: 714-505-2976
Mailing address:
  • Phone: 714-505-2966
  • Fax: 714-505-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT38984
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: