Provider Demographics
NPI:1366896797
Name:KHWAJA, ANSAB (MD PC)
Entity type:Individual
Prefix:
First Name:ANSAB
Middle Name:
Last Name:KHWAJA
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6542 SE LAKE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2245
Mailing Address - Country:US
Mailing Address - Phone:425-736-9426
Mailing Address - Fax:
Practice Address - Street 1:6542 SE LAKE RD STE 201
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2245
Practice Address - Country:US
Practice Address - Phone:503-659-1769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR75494207Q00000X, 207X00000X
CT70189207X00000X
390200000X
ORMD214297207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program