Provider Demographics
NPI:1487295549
Name:TRAN, KELLY TRAM (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:TRAM
Last Name:TRAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRAM
Other - Middle Name:BAO
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9392 DOWNING CIR
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6520
Mailing Address - Country:US
Mailing Address - Phone:714-654-3750
Mailing Address - Fax:
Practice Address - Street 1:12488 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2625
Practice Address - Country:US
Practice Address - Phone:909-613-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363A00000X
CAPA57368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical