Provider Demographics
NPI:1275745333
Name:KHAN, SOHAIL A (PA)
Entity Type:Individual
Prefix:
First Name:SOHAIL
Middle Name:A
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 1:10175 FORTUNE PKWY UNIT 1106
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6757
Mailing Address - Country:US
Mailing Address - Phone:904-379-5928
Mailing Address - Fax:904-379-5967
Practice Address - Street 1:10175 FORTUNE PKWY UNIT 1106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6757
Practice Address - Country:US
Practice Address - Phone:904-379-5928
Practice Address - Fax:904-379-5967
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292057300Medicaid
FLPA 9102828OtherPHYS ASSIST LICENSE
P00407536OtherRAILROAD MEDICARE
FL292057300Medicaid
FLPA 9102828OtherPHYS ASSIST LICENSE