Provider Demographics
NPI:1437898384
Name:OWEN, MICHAEL TYLER (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TYLER
Last Name:OWEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 SAN PEDRO DR NE APT 40
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2551
Mailing Address - Country:US
Mailing Address - Phone:575-706-4389
Mailing Address - Fax:
Practice Address - Street 1:3401 4TH ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-2423
Practice Address - Country:US
Practice Address - Phone:505-994-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2023-0025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant