Provider Demographics
NPI:1841501004
Name:TRAN, KENNY-BAO (MD)
Entity type:Individual
Prefix:
First Name:KENNY-BAO
Middle Name:
Last Name:TRAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 924
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78767-0924
Mailing Address - Country:US
Mailing Address - Phone:512-942-4700
Mailing Address - Fax:
Practice Address - Street 1:2000 SCENIC DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7726
Practice Address - Country:US
Practice Address - Phone:512-942-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54297208100000X
390200000X
TXQ1520208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN250000973Medicare PIN