Healthcare Provider Details

I. General information

NPI: 1437591971
Provider Name (Legal Business Name): RANDALL LEE OWEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 06/29/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 WASHINGTON AVE
HAMDEN CT
06518-3267
US

IV. Provider business mailing address

7 MONTOYA DR
BRANFORD CT
06405-2533
US

V. Phone/Fax

Practice location:
  • Phone: 203-865-6784
  • Fax: 203-865-6788
Mailing address:
  • Phone: 475-434-1183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA056252
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004314
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.003095
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number23.003095
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number23.003095
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: