Provider Demographics
NPI:1093290132
Name:KHANAL, NISHA (PA-C)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:KHANAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NISHA
Other - Middle Name:KHANAL
Other - Last Name:PANTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5999
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97228-5999
Mailing Address - Country:US
Mailing Address - Phone:541-500-2500
Mailing Address - Fax:541-500-2700
Practice Address - Street 1:4001 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-3345
Practice Address - Country:US
Practice Address - Phone:509-410-0746
Practice Address - Fax:509-410-0749
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2945363AS0400X
WAPA61198230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2192132Medicaid