Provider Demographics
NPI:1376165118
Name:ALLEN, KHORI-JON (PA-C)
Entity Type:Individual
Prefix:
First Name:KHORI-JON
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 OLD WASHINGTON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3234
Mailing Address - Country:US
Mailing Address - Phone:301-932-5890
Mailing Address - Fax:
Practice Address - Street 1:3510 OLD WASHINGTON RD STE 100
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3234
Practice Address - Country:US
Practice Address - Phone:301-932-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant