=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982367306
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN TRAN PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2021
-----------------------------------------------------
Last Update Date | 06/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 MONTEREY HWY STE 10
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95112-6126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-477-8080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1355 MCCANDLESS DR APT 336
-----------------------------------------------------
City | MILPITAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95035-8160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-613-9959
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------