=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740964014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MI NI THI TRAN CAA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2023
-----------------------------------------------------
Last Update Date | 11/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 PRUDENTIAL DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-8202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-237-8755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1918 PALMA CEIA ST
-----------------------------------------------------
City | PALATKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32177-5957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-237-8755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number | AA899
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------