Provider Demographics
NPI:1134936545
Name:KHAWAJA, JACK NICOLAS
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:NICOLAS
Last Name:KHAWAJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2842 47TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1208
Mailing Address - Country:US
Mailing Address - Phone:347-479-5166
Mailing Address - Fax:
Practice Address - Street 1:2842 47TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-1208
Practice Address - Country:US
Practice Address - Phone:347-479-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies