Healthcare Provider Details

I. General information

NPI: 1871045773
Provider Name (Legal Business Name): ANNUM KHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TYSONS BLVD STE 120
MC LEAN VA
22102-4227
US

IV. Provider business mailing address

11350 MCCORMICK RD EXECUTIVE PLAZA 1 STE 501
HUNT VALLEY MD
21031
US

V. Phone/Fax

Practice location:
  • Phone: 703-914-8000
  • Fax: 703-642-1876
Mailing address:
  • Phone: 703-738-4331
  • Fax: 703-642-1876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110005341
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: