Provider Demographics
NPI:1982250908
Name:KHANSA, MARIAM
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:KHANSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12508 JONES MALTSBERGER RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-4215
Mailing Address - Country:US
Mailing Address - Phone:210-590-4000
Mailing Address - Fax:210-590-4585
Practice Address - Street 1:711 W 38TH ST STE C11
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1137
Practice Address - Country:US
Practice Address - Phone:512-302-3922
Practice Address - Fax:512-302-3921
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist