Provider Demographics
NPI:1093870172
Name:KHAN, WAJAHAT ALI (MD)
Entity Type:Individual
Prefix:
First Name:WAJAHAT
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 KIMBALL DR
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1228
Mailing Address - Country:US
Mailing Address - Phone:253-858-9192
Mailing Address - Fax:253-858-4348
Practice Address - Street 1:6401 KIMBALL DR
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1228
Practice Address - Country:US
Practice Address - Phone:253-858-9192
Practice Address - Fax:253-858-4348
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044018208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0231161OtherSTATE L&I
WA0231156OtherSTATE L&I
WA8414021Medicaid
WA0221363OtherSTATE L&I
WA0217036OtherSTATE L&I
WA0258715OtherSTATE L&I
WA0217036OtherSTATE L&I
G8863338Medicare PIN
WA0231156OtherSTATE L&I
WA0231161OtherSTATE L&I
WA8850301Medicare ID - Type UnspecifiedKITSAP MEDICARE PROVIDER
WA8850297Medicare ID - Type UnspecifiedKING COUNTY MEDICARE
WA8850300Medicare ID - Type UnspecifiedTHURSTON COUNTY MEDICARE
WA8850299Medicare ID - Type UnspecifiedPIERCE COUNTY MEDICARE
WA8850298Medicare ID - Type UnspecifiedSNOHOMISH COUNTY MEDICARE