Provider Demographics
NPI:1437647468
Name:KHAN, NISAR (MD)
Entity Type:Individual
Prefix:
First Name:NISAR
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:549 FAIR ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1419
Practice Address - Country:US
Practice Address - Phone:570-387-2055
Practice Address - Fax:570-387-2056
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2023-11-15
Deactivation Date:2018-11-29
Deactivation Code:
Reactivation Date:2019-01-11
Provider Licenses
StateLicense IDTaxonomies
PAMD4758772083A0300X, 2083P0500X, 2083P0901X, 2084P0802X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program