Basic Information
| Provider Information | |||||||||
| NPI: | 1700879723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHALIL | ||||||||
| FirstName: | WALEED | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 TEMPLE HILL RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125530000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455653700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 70 DUBOIS ST | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125504851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455682305 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 009992 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02651141 | 05 | NY | MEDICAID |