Provider Demographics
NPI:1194525410
Name:KHOSA, PRABHJOT KAUR
Entity type:Individual
Prefix:
First Name:PRABHJOT
Middle Name:KAUR
Last Name:KHOSA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 ANTINORI WAY
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-8037
Mailing Address - Country:US
Mailing Address - Phone:209-607-0245
Mailing Address - Fax:
Practice Address - Street 1:2148 ANTINORI WAY
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-8037
Practice Address - Country:US
Practice Address - Phone:209-607-0245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95034241363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health