Provider Demographics
NPI:1508662008
Name:KHAN, KANWAL
Entity type:Individual
Prefix:
First Name:KANWAL
Middle Name:
Last Name:KHAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-1436
Mailing Address - Country:US
Mailing Address - Phone:347-447-5968
Mailing Address - Fax:
Practice Address - Street 1:104 HOWELL AVE
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863-1436
Practice Address - Country:US
Practice Address - Phone:347-447-5968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312067363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health