Healthcare Provider Details

I. General information

NPI: 1508060930
Provider Name (Legal Business Name): CANDACE OEN P. A. -C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13175 E HIGHWAY 169
DEWEY AZ
86327-7372
US

IV. Provider business mailing address

PO BOX 1046
DEWEY AZ
86327-1046
US

V. Phone/Fax

Practice location:
  • Phone: 928-632-0111
  • Fax:
Mailing address:
  • Phone: 928-632-8278
  • Fax: 928-632-0105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2077
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: