Healthcare Provider Details

I. General information

NPI: 1659221364
Provider Name (Legal Business Name): KENNY TAN TRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14281 BEACH BLVD
WESTMINSTER CA
92683-4567
US

IV. Provider business mailing address

1731 E 120TH ST
LOS ANGELES CA
90059-3051
US

V. Phone/Fax

Practice location:
  • Phone: 714-893-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67743
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: