Healthcare Provider Details

I. General information

NPI: 1215743380
Provider Name (Legal Business Name): MOMINA KHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 GOLD STAR BLVD
WORCESTER MA
01606-2812
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 508-426-9002
  • Fax: 508-426-9070
Mailing address:
  • Phone: 603-410-6700
  • Fax: 603-319-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: