Provider Demographics
NPI:1750455408
Name:KHAN, AHSAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:AHSAN
Middle Name:M
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:PO BOX 3649
Mailing Address - Street 2:SRC-CREDENTIALING
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2803
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47475-20207R00000X
WAMD60035913207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0248464OtherSTATE L&I
WA1750455408Medicaid
WA1750455408Medicaid
WA0248464OtherSTATE L&I