Basic Information
| Provider Information | |||||||||
| NPI: | 1386283968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAZAN | ||||||||
| FirstName: | MARINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 GREENE LN | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080031147 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 TANNER ST | ||||||||
| Address2: | |||||||||
| City: | HADDONFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080332453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8445422273 | ||||||||
| FaxNumber: | 8564290891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2019 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | PENDING | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 26NJ01072600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.