Provider Demographics
NPI:1275160590
Name:KHAN, ABDUL QAYYUM
Entity Type:Individual
Prefix:
First Name:ABDUL
Middle Name:QAYYUM
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SULTANA DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4874
Mailing Address - Country:US
Mailing Address - Phone:845-542-2716
Mailing Address - Fax:
Practice Address - Street 1:850 SULTANA DR
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4874
Practice Address - Country:US
Practice Address - Phone:845-542-2716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver