Provider Demographics
NPI:1922798933
Name:BHAIDAS, KHUSHBOO
Entity Type:Individual
Prefix:
First Name:KHUSHBOO
Middle Name:
Last Name:BHAIDAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 STAFFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2120
Mailing Address - Country:US
Mailing Address - Phone:570-677-2448
Mailing Address - Fax:570-955-1225
Practice Address - Street 1:200 STAFFORD AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2120
Practice Address - Country:US
Practice Address - Phone:570-677-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP026091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily