Provider Demographics
NPI:1114577038
Name:MANASRAH, KHALED (RSA)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:MANASRAH
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 JEFFERY CT
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-1332
Mailing Address - Country:US
Mailing Address - Phone:224-288-8847
Mailing Address - Fax:
Practice Address - Street 1:904 JEFFERY CT
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-1332
Practice Address - Country:US
Practice Address - Phone:224-288-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000648363AS0400X, 246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant