Healthcare Provider Details

I. General information

NPI: 1790791325
Provider Name (Legal Business Name): ISMAT NASREEN KHAN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 E 2ND ST STE B
AUSTIN TX
78702-4491
US

IV. Provider business mailing address

PO BOX 3548
AUSTIN TX
78764-3548
US

V. Phone/Fax

Practice location:
  • Phone: 512-804-3350
  • Fax: 512-804-3672
Mailing address:
  • Phone: 512-445-7787
  • Fax: 512-440-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02762
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: