Basic Information
| Provider Information | |||||||||
| NPI: | 1801969886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | SHIREEN | ||||||||
| MiddleName: | ENETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1535 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984011535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Practice Location | |||||||||
| Address1: | 1304 FAWCETT AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984021911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2537614200 | ||||||||
| FaxNumber: | 2533833553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 09/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 00027513 | WA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | MD00036228 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 7252KH | 01 | WA | REGENCE BLUE SHIELD UNION AVENUE OPEN | OTHER | 8238743 | 05 | WA | MEDICAID | AB36525 | 01 | WA | MEDICARE PIN TRA KING COUNTY | OTHER | KH8284 | 01 | WA | REGENCE BLUE SHIELD TRA | OTHER | 8951843 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST | OTHER | 126222 | 01 | WA | LABOR AND INDUSTRIES/WC TRA | OTHER | G8882898 | 01 | WA | PTAN-MIO1 | OTHER | 300095009 | 01 | WA | RR MEDICARE TRA | OTHER | 157409 | 01 | WA | LABOR AND INDUSTRIES/WC UNION AVENUE OPEN | OTHER | G8927711 | 01 | WA | PTAN-UAOM | OTHER | 0249541 | 01 | WA | LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST | OTHER | 300095008 | 01 | WA | RR MEDICARE UNION AVENUE OPEN | OTHER | AB34171 | 01 | WA | MEDICARE PIN UNION AVE OPEN | OTHER |