Provider Demographics
NPI:1548223043
Name:KHALSA, JIWAN SK (DOM)
Entity Type:Individual
Prefix:MRS
First Name:JIWAN
Middle Name:SK
Last Name:KHALSA
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N PASEO DE ONATE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:505-753-3369
Mailing Address - Fax:505-753-4006
Practice Address - Street 1:415 N PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-753-3369
Practice Address - Fax:505-753-4006
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM444171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist