Provider Demographics
NPI:1437591971
Name:OWEN, RANDALL LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:LEE
Last Name:OWEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MONTOYA DR
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2533
Mailing Address - Country:US
Mailing Address - Phone:475-434-1183
Mailing Address - Fax:
Practice Address - Street 1:9 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3267
Practice Address - Country:US
Practice Address - Phone:203-865-6784
Practice Address - Fax:203-865-6788
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056252363A00000X
VA0110004314363A00000X
CT23.003095363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical