Provider Demographics
NPI:1376563601
Name:KHAN, JESSICA SANTIAGO (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SANTIAGO
Last Name:KHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICAN
Other - Middle Name:HILARIO
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1701 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4511
Mailing Address - Country:US
Mailing Address - Phone:253-697-5767
Mailing Address - Fax:
Practice Address - Street 1:1701 3RD ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4511
Practice Address - Country:US
Practice Address - Phone:253-697-5767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4469207R00000X
WAMD60602505207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G14475Medicare UPIN
TX80320NMedicare PIN