MEDICARE: AUDREY KINNEAR OWEIMRIN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	6432	CT

General Provider Information

NPI Number	:	1053173427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY KINNEAR OWEIMRIN PA-C

Provider Business Mailing Address
First Line	:	342 N MAIN ST STE 350
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2530
Country	:	US
Telephone Number	:	860-296-4022
Fax Number	:

Provider Business Practice Location Address
First Line	:	342 N MAIN ST STE 350
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06117-2530
Country	:	US
Telephone Number	:	860-296-4022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2024
Last Update Date	:	01/30/2024

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