Provider Demographics
NPI:1073280434
Name:KHAN, SIDRAH M
Entity Type:Individual
Prefix:
First Name:SIDRAH
Middle Name:M
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 1:75 WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:EAST WINDSOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-2608
Mailing Address - Country:US
Mailing Address - Phone:916-267-7947
Mailing Address - Fax:
Practice Address - Street 1:75 WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:EAST WINDSOR
Practice Address - State:NJ
Practice Address - Zip Code:08520-2608
Practice Address - Country:US
Practice Address - Phone:916-267-7947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCF09210533363LF0000X
VAF09210533363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily