Provider Demographics
NPI:1821046392
Name:OWEN, BRET R (PA)
Entity Type:Individual
Prefix:MR
First Name:BRET
Middle Name:R
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 1:16620 COBBLESTONE CIR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2825 PARKLAWN DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4201
Practice Address - Country:US
Practice Address - Phone:405-610-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100113210AMedicaid
OKS35857Medicare UPIN
OKPA00819Medicare ID - Type Unspecified