Provider Demographics
NPI:1649709031
Name:OWEN, ANDREW LYN (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:LYN
Last Name:OWEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:550 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-1816
Mailing Address - Country:US
Mailing Address - Phone:386-336-3633
Mailing Address - Fax:
Practice Address - Street 1:550 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091
Practice Address - Country:US
Practice Address - Phone:904-364-2900
Practice Address - Fax:904-364-2901
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMEDICAREOtherJB638Y
FL021850300Medicaid