Basic Information
| Provider Information | |||||||||
| NPI: | 1992877344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | AYESHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAUQEER | ||||||||
| OtherFirstName: | AYESHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1001 ROCK QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276103825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198333111 | ||||||||
| FaxNumber: | 9198343118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 ROCK QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276103825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198333111 | ||||||||
| FaxNumber: | 9198343118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 07/11/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 058338 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 058338 | GA | N | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | 2016-00151 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 471357534F | 05 | GA | MEDICAID | 1609816123 | 01 | GA | GEORGIA CLINIC PC GROUP NPI # | OTHER | BT9987869 | 01 | NC | DEA LICENSE | OTHER | 471357534D | 05 | GA | MEDICAID | 2016-00151 | 01 | NC | NORTH CAROLINA MEDICAL BOARD LICENSE | OTHER | 471357534E | 05 | GA | MEDICAID |