Provider Demographics
NPI:1215974498
Name:PROFESSIONAL GASTROENTEROLOGY & NUTRITION ASSOCIATES, P.A.
Entity type:Organization
Organization Name:PROFESSIONAL GASTROENTEROLOGY & NUTRITION ASSOCIATES, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:C
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-323-8868
Mailing Address - Street 1:8110 COUNTY ROAD 44 LEG A
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34788-3704
Mailing Address - Country:US
Mailing Address - Phone:352-323-8868
Mailing Address - Fax:
Practice Address - Street 1:8110 COUNTY ROAD 44 LEG A
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-3704
Practice Address - Country:US
Practice Address - Phone:352-323-8868
Practice Address - Fax:352-323-8865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0163Medicare ID - Type Unspecified