Healthcare Provider Details

I. General information

NPI: 1629308135
Provider Name (Legal Business Name): OMAR AHMED KHAN DNP, APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2010
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N PRAIRIE AVE
INGLEWOOD CA
90301-4502
US

IV. Provider business mailing address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

V. Phone/Fax

Practice location:
  • Phone: 310-846-2100
  • Fax:
Mailing address:
  • Phone: 310-390-6612
  • Fax: 310-398-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN.0995819-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95008495
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number851513
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: