Provider Demographics
NPI:1679754329
Name:KHAWAJA, SIDRAH (R-PAC)
Entity type:Individual
Prefix:
First Name:SIDRAH
Middle Name:
Last Name:KHAWAJA
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-4517
Mailing Address - Country:US
Mailing Address - Phone:816-932-3679
Mailing Address - Fax:816-932-9089
Practice Address - Street 1:4401 WORNALL RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3220
Practice Address - Country:US
Practice Address - Phone:816-932-3679
Practice Address - Fax:816-932-9089
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012059-1363A00000X
MDC04020363A00000X
MO2019033838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD180417Y9QMedicare PIN