Healthcare Provider Details

I. General information

NPI: 1164907507
Provider Name (Legal Business Name): MARIAM D OWEIS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 YOUNG AVE STE 245
MOORESTOWN NJ
08057-3132
US

IV. Provider business mailing address

4 EVES DR STE A100
MARLTON NJ
08053-3126
US

V. Phone/Fax

Practice location:
  • Phone: 609-267-9400
  • Fax: 609-267-9457
Mailing address:
  • Phone: 609-267-9400
  • Fax: 609-267-9457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00496400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: