Basic Information
| Provider Information | |||||||||
| NPI: | 1992252266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDUL | ||||||||
| FirstName: | KHABEER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1704 W STOCKTON ST | ||||||||
| Address2: | |||||||||
| City: | EDMONTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421298137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704324800 | ||||||||
| FaxNumber: | 2704324804 | ||||||||
| Practice Location | |||||||||
| Address1: | 1704 W STOCKTON ST | ||||||||
| Address2: | |||||||||
| City: | EDMONTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421298137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704324800 | ||||||||
| FaxNumber: | 2704324804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2016 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 81327 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 21562 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 189364 | TN | N | Nursing Service Providers | Registered Nurse |
No ID Information.