Basic Information
| Provider Information | |||||||||
| NPI: | 1700865797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BASRAI | ||||||||
| FirstName: | KHAISHOON | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367181000 | ||||||||
| FaxNumber: | 3367181052 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 MOORE RD | ||||||||
| Address2: | |||||||||
| City: | KING | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270218703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369834346 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200401615 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5900381 | 05 | NC | MEDICAID |