Healthcare Provider Details

I. General information

NPI: 1679613970
Provider Name (Legal Business Name): ELMER GARI OWENS P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 18 & TAFT AVENUE
FAIRFAX OK
74637-0219
US

IV. Provider business mailing address

12500 NE 36TH ST
CHOCTAW OK
73020-9111
US

V. Phone/Fax

Practice location:
  • Phone: 918-642-3291
  • Fax: 918-642-3694
Mailing address:
  • Phone: 405-769-3221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number619
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: