Provider Demographics
NPI:1780579870
Name:KHAN, TUBA
Entity type:Individual
Prefix:
First Name:TUBA
Middle Name:
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 1:64 GRAY AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1094
Mailing Address - Country:US
Mailing Address - Phone:631-520-4187
Mailing Address - Fax:
Practice Address - Street 1:64 GRAY AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1094
Practice Address - Country:US
Practice Address - Phone:631-520-4187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353212164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse