Provider Demographics
NPI:1164227195
Name:KHALED, IRENE AMY (PA-C)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:AMY
Last Name:KHALED
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 N ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-1134
Mailing Address - Country:US
Mailing Address - Phone:703-537-9997
Mailing Address - Fax:
Practice Address - Street 1:500 VONDERBURG DR STE 215
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5977
Practice Address - Country:US
Practice Address - Phone:813-337-6178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-14
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9119788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant