Provider Demographics
NPI:1457065252
Name:KHANDJIAN, MISTY LEIGH (MPAS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:LEIGH
Last Name:KHANDJIAN
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:MISTY
Other - Middle Name:LEIGH
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1779 TORULUSA CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5556
Mailing Address - Country:US
Mailing Address - Phone:770-561-0689
Mailing Address - Fax:
Practice Address - Street 1:1401 CENTERVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4638
Practice Address - Country:US
Practice Address - Phone:850-877-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116931363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant