Provider Demographics
NPI:1023665221
Name:SURTANI, KHUSBOO (PA-C)
Entity type:Individual
Prefix:
First Name:KHUSBOO
Middle Name:
Last Name:SURTANI
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 1:12410 TOEPPERWEIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3230
Mailing Address - Country:US
Mailing Address - Phone:210-742-6555
Mailing Address - Fax:
Practice Address - Street 1:12410 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3230
Practice Address - Country:US
Practice Address - Phone:210-742-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2024-02-12
Deactivation Date:2024-01-08
Deactivation Code:
Reactivation Date:2024-02-09
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TXPA17609363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician