=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588964456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHADEER KHAN MSN, DNP, FNP, PMHNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2010
-----------------------------------------------------
Last Update Date | 11/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1875 W REDONDO BEACH BLVD STE 308
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-3644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-387-2054
-----------------------------------------------------
Fax | 310-362-3598
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 PHELAN LN
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90278-5309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-387-2054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 19864
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 19864
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------