Healthcare Provider Details

I. General information

NPI: 1649828096
Provider Name (Legal Business Name): SHAWN S. KHAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2019
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6944 E BROADWAY RD
MESA AZ
85208-1916
US

IV. Provider business mailing address

1462 CLIFTON RD NE STE 280
ATLANTA GA
30322-1000
US

V. Phone/Fax

Practice location:
  • Phone: 855-817-4687
  • Fax: 866-913-0013
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12032
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110008474
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: