Healthcare Provider Details

I. General information

NPI: 1235620675
Provider Name (Legal Business Name): LAN TRAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901
US

IV. Provider business mailing address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-2183
  • Fax: 706-774-7002
Mailing address:
  • Phone: 706-774-2183
  • Fax: 706-774-7002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5216
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-40748
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: