Healthcare Provider Details

I. General information

NPI: 1932861648
Provider Name (Legal Business Name): MANAAL KHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2021
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24224 JOY RD
REDFORD MI
48239-1215
US

IV. Provider business mailing address

24224 JOY RD
REDFORD MI
48239-1215
US

V. Phone/Fax

Practice location:
  • Phone: 313-561-9090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010660
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: