Provider Demographics
NPI:1619078375
Name:KHAN, TONYA A (PA-C)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:A
Last Name:KHAN
Suffix:
Gender:F
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 1:1300 W TERRELL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2822
Practice Address - Country:US
Practice Address - Phone:817-769-3603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX800N92OtherBCBS
TX204492701Medicaid
TX204492704Medicaid
P00821162OtherMEDICARE RR
TXTXB146797Medicare PIN
TXTXB146798Medicare PIN
TXTXB146796Medicare PIN
P00821162OtherMEDICARE RR