Healthcare Provider Details

I. General information

NPI: 1811904071
Provider Name (Legal Business Name): MAX EDWARD OWEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 WEST MAIN
HENRYETTA OK
74437-3893
US

IV. Provider business mailing address

2405 W MAIN ST
HENRYETTA OK
74437-3893
US

V. Phone/Fax

Practice location:
  • Phone: 918-650-1180
  • Fax: 918-650-1294
Mailing address:
  • Phone: 918-650-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1540
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: