Basic Information
| Provider Information | |||||||||
| NPI: | 1629308135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | OMAR | ||||||||
| MiddleName: | AHMED | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 N PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | INGLEWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 903014502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108462100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 851513 | CA | N | Nursing Service Providers | Registered Nurse | 363LP0808X | APN.0995819-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 95008495 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.