MEDICARE: NASIRA HUSSAIN KHAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA07883	TX

General Provider Information

NPI Number	:	1508101486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NASIRA HUSSAIN KHAN PA-C

Provider Business Mailing Address
First Line	:	10409 LAKE BEND TRL
Second Line	:
City	:	HURST
State	:	TX
Zip	:	76053-7822
Country	:	US
Telephone Number	:	682-472-4678
Fax Number	:

Provider Business Practice Location Address
First Line	:	4819 RIVER OAKS BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-3098
Country	:	US
Telephone Number	:	817-626-9744
Fax Number	:	817-626-9962

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2012
Last Update Date	:	10/23/2013

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