MEDICARE: NICHOLAS OWENS

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	146M00000X	Intermediate Emergency Medical Technician
2	172A00000X	Driver

General Provider Information

NPI Number	:	1396217303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS OWENS

Provider Business Mailing Address
First Line	:	4111 ROBERT E LEE DR
Second Line	:
City	:	NORTH PRINCE GEORGE
State	:	VA
Zip	:	23860-7529
Country	:	US
Telephone Number	:	804-439-1264
Fax Number	:

Provider Business Practice Location Address
First Line	:	4111 ROBERT E LEE DR
Second Line	:
City	:	NORTH PRINCE GEORGE
State	:	VA
Zip	:	23860-7529
Country	:	US
Telephone Number	:	804-439-1264
Fax Number	:

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

Provider Enumeration Date	:	01/02/2019
Last Update Date	:	01/02/2019

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