Provider Demographics
NPI:1700327327
Name:OWEN, MARTHA BOON (PA-C)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:BOON
Last Name:OWEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:BOON
Other - Last Name:FRITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2637 E 36TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-2803
Mailing Address - Country:US
Mailing Address - Phone:918-557-1844
Mailing Address - Fax:
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1902
Practice Address - Country:US
Practice Address - Phone:918-494-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant