Provider Demographics
NPI:1851175152
Name:OWENS, TREVOR DALE (AT STUDENT)
Entity Type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:DALE
Last Name:OWENS
Suffix:
Gender:M
Credentials:AT STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4136 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-0148
Mailing Address - Country:US
Mailing Address - Phone:229-977-1412
Mailing Address - Fax:
Practice Address - Street 1:4136 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31757-0148
Practice Address - Country:US
Practice Address - Phone:229-977-1412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program