Provider Demographics
NPI:1902286065
Name:KHAN, MUBEEN A
Entity Type:Individual
Prefix:
First Name:MUBEEN
Middle Name:A
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N84W16889 MENOMONEE AVE
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-2810
Mailing Address - Country:US
Mailing Address - Phone:262-251-7500
Mailing Address - Fax:
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051
Practice Address - Country:US
Practice Address - Phone:262-251-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69669207Q00000X
IN01078688A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080862Medicaid