Provider Demographics
NPI:1396248852
Name:TRAN, JEREMIAH EUGENE (AG-ACNPC)
Entity type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:EUGENE
Last Name:TRAN
Suffix:
Gender:M
Credentials:AG-ACNPC
Other - Prefix:MR
Other - First Name:JEREMIAH
Other - Middle Name:
Other - Last Name:CONWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6115 W NORTH LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-1246
Mailing Address - Country:US
Mailing Address - Phone:602-888-2662
Mailing Address - Fax:602-887-5756
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:602-249-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-12
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN172376163WC0200X
AZAP11167363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Multi-Specialty