Healthcare Provider Details

I. General information

NPI: 1104130947
Provider Name (Legal Business Name): REHAN E KHAN DNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W 114TH ST APT. 73
NEW YORK NY
10025
US

IV. Provider business mailing address

609 W 114TH ST APT. 73
NEW YORK NY
10025-7972
US

V. Phone/Fax

Practice location:
  • Phone: 917-597-3533
  • Fax: 212-665-6895
Mailing address:
  • Phone: 917-597-3533
  • Fax: 212-665-6895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number632777
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number343149
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number343149
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number343149
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: