Provider Demographics
NPI:1013558246
Name:KOMIYA-FAKHRAI, DAN (RN, BSN)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:KOMIYA-FAKHRAI
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:
Other - Last Name:KOMIYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:3344 SW MARIPOSA PL
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66614-6500
Mailing Address - Country:US
Mailing Address - Phone:785-608-6125
Mailing Address - Fax:
Practice Address - Street 1:3707 SW 6TH AVE
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-2084
Practice Address - Country:US
Practice Address - Phone:785-270-4650
Practice Address - Fax:785-270-4603
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS131838163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse