Provider Demographics
NPI:1033578745
Name:KHAN, MATTIE
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 N VANCOUVER AVE UNIT 11F
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2784
Mailing Address - Country:US
Mailing Address - Phone:503-935-3493
Mailing Address - Fax:
Practice Address - Street 1:5209 N VANCOUVER AVE UNIT 11F
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2784
Practice Address - Country:US
Practice Address - Phone:503-935-3493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR800374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW0183OtherTRADITIONAL HEALTH WORKER