Provider Demographics
NPI:1821455262
Name:KHAWAJA, LAURA (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KHAWAJA
Suffix:
Gender:F
Credentials:PA
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 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:9776 BONITA BEACH RD SE STE 201A
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4775
Practice Address - Country:US
Practice Address - Phone:239-947-3092
Practice Address - Fax:239-947-5298
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO9D5BOtherBCBS
FL104522800Medicaid