Basic Information
Provider Information
NPI: 1003001587
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TRAN
FirstName: MARY
MiddleName: CHAU
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 280 SAND HILL RD
Address2:  
City: MIDDLETOWN
State: CT
PostalCode: 064574533
CountryCode: US
TelephoneNumber: 9854130732
FaxNumber:  
Practice Location
Address1: 400 SAYBROOK RD STE 205
Address2:  
City: MIDDLETOWN
State: CT
PostalCode: 064574775
CountryCode: US
TelephoneNumber: 8883440007
FaxNumber: 8603431004
Other Information
ProviderEnumerationDate: 09/07/2007
LastUpdateDate: 11/02/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X3091CTY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 
363AS0400X012657NYN Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical

No ID Information.


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