Provider Demographics
NPI:1093795726
Name:KHAN, MUMTAZ (PA)
Entity Type:Individual
Prefix:
First Name:MUMTAZ
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:BLANCHFIELD HOSPITAL
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-798-8388
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:BLANCHFIELD HOSPITAL
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42873300Medicaid
12040-0005Medicare ID - Type Unspecified
WI42873300Medicaid
11068-0015Medicare ID - Type Unspecified
12075-0006Medicare ID - Type Unspecified