Healthcare Provider Details

I. General information

NPI: 1376368688
Provider Name (Legal Business Name): MARY THERESA TRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 01/17/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06106-3315
US

IV. Provider business mailing address

25 BIRDSEY AVE
MIDDLETOWN CT
06457-4301
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-5000
  • Fax:
Mailing address:
  • Phone: 860-501-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6933
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6933
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: