Provider Demographics
NPI:1811904071
Name:OWEN, MAX EDWARD (PA)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:EDWARD
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 1:2405 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-3893
Mailing Address - Country:US
Mailing Address - Phone:918-650-1180
Mailing Address - Fax:
Practice Address - Street 1:2405 WEST MAIN
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-3893
Practice Address - Country:US
Practice Address - Phone:918-650-1180
Practice Address - Fax:918-650-1294
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1540OtherPHYSICIAN ASSISTANTS