Healthcare Provider Details

I. General information

NPI: 1174097448
Provider Name (Legal Business Name): MARIO ANTWAN OWENS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2019
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 SERENE WAY
UNION CITY GA
30291-5153
US

IV. Provider business mailing address

4150 SERENE WAY
UNION CITY GA
30291-5153
US

V. Phone/Fax

Practice location:
  • Phone: 678-215-9947
  • Fax:
Mailing address:
  • Phone: 678-215-9947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF01190896
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: