Provider Demographics
NPI:1992066302
Name:TRAN, ANDY QUOC
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:QUOC
Last Name:TRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18102 IRVINE BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3402
Mailing Address - Country:US
Mailing Address - Phone:714-505-2966
Mailing Address - Fax:714-505-2976
Practice Address - Street 1:18102 IRVINE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3402
Practice Address - Country:US
Practice Address - Phone:714-505-2966
Practice Address - Fax:714-505-2976
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38984225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19679Medicare PIN