MEDICARE: DR. NICOLE MARIE OWENS M.D.

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	207N00000X	Dermatology Physician	N4644	TX

General Provider Information

NPI Number	:	1154312080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE MARIE OWENS M.D.

Provider Business Mailing Address
First Line	:	4919 MEMORIAL HWY STE 150
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33634-7516
Country	:	US
Telephone Number	:	813-333-1512
Fax Number	:	813-333-1561

Provider Business Practice Location Address
First Line	:	2632 BROADWAY ST
Second Line	:	SUITE 202 SOUTH
City	:	SAN ANTONIO
State	:	TX
Zip	:	78215-1137
Country	:	US
Telephone Number	:	210-541-4884
Fax Number	:	210-541-4900

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	03/31/2022

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