Provider Demographics
NPI:1063824100
Name:KHAN, NAWAB (SA-C)
Entity Type:Individual
Prefix:
First Name:NAWAB
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 FULLER WISER RD
Mailing Address - Street 2:APT 1003H
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76039-4632
Mailing Address - Country:US
Mailing Address - Phone:817-583-6603
Mailing Address - Fax:682-308-0339
Practice Address - Street 1:1800 FULLER WISER RD
Practice Address - Street 2:APT 1003H
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76039-4632
Practice Address - Country:US
Practice Address - Phone:817-583-6603
Practice Address - Fax:682-308-0339
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00537246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant