Provider Demographics
NPI:1679613970
Name:OWENS, ELMER GARI (PA)
Entity Type:Individual
Prefix:
First Name:ELMER
Middle Name:GARI
Last Name:OWENS
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 1:12500 NE 36TH ST
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-9111
Mailing Address - Country:US
Mailing Address - Phone:405-769-3221
Mailing Address - Fax:
Practice Address - Street 1:HWY 18 & TAFT AVENUE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-0219
Practice Address - Country:US
Practice Address - Phone:918-642-3291
Practice Address - Fax:918-642-3694
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100055050AMedicaid
OKS07254Medicare UPIN