Provider Demographics
NPI:1386031748
Name:OWENS, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:OWENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 DEER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-4148
Mailing Address - Country:US
Mailing Address - Phone:585-402-8669
Mailing Address - Fax:
Practice Address - Street 1:1101 CAMDEN AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-6837
Practice Address - Country:US
Practice Address - Phone:410-543-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
PAMA064452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program