MEDICARE: KELLY TRAM TRAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant
2	363A00000X	Physician Assistant	PA57368	CA

General Provider Information

NPI Number	:	1487295549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY TRAM TRAN PA-C

Provider Business Mailing Address
First Line	:	9392 DOWNING CIR
Second Line	:
City	:	WESTMINSTER
State	:	CA
Zip	:	92683-6520
Country	:	US
Telephone Number	:	714-654-3750
Fax Number	:

Provider Business Practice Location Address
First Line	:	520 N PROSPECT AVE STE 302
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90277-3043
Country	:	US
Telephone Number	:	310-798-1515
Fax Number	:	310-798-3131

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2019
Last Update Date	:	01/13/2026

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