MEDICARE: MISS AMANDA AMINA KHORDAJI PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2119733	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2119733	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1184180960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS AMANDA AMINA KHORDAJI PTA

Provider Business Mailing Address
First Line	:	21122 BRIDGE FALLS CT
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77449-5067
Country	:	US
Telephone Number	:	832-623-4107
Fax Number	:

Provider Business Practice Location Address
First Line	:	734 NORTH LOOP
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77009-1043
Country	:	US
Telephone Number	:	713-868-2766
Fax Number	:	713-868-7575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2019
Last Update Date	:	09/08/2022

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