Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 21499 | NE |
NPI | 1003822941 |
---|---|
Provider Name | Masood Khan |
First Address | Scottsbluff, NE 69361-4669 |
Second Address | Scottsbluff, NE 69361-4669 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
21499 | STATE LICENSE (01) | NE |
H77865 | (02) | NE |