Basic Information
| Provider Information | |||||||||
| NPI: | 1821455262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAWAJA | ||||||||
| FirstName: | LAURA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26067 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841260067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 VANDERBILT BEACH RD | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341088708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396248220 | ||||||||
| FaxNumber: | 2396248221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2016 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9109324 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | O9D5B | 01 | FL | BCBS | OTHER | 104522800 | 05 | FL | MEDICAID |