Basic Information
| Provider Information | |||||||||
| NPI: | 1811904071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | MAX | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENRYETTA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744373893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186501180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2405 WEST MAIN | ||||||||
| Address2: | |||||||||
| City: | HENRYETTA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744373893 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186501180 | ||||||||
| FaxNumber: | 9186501294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/19/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1540 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1540 | 01 | OK | PHYSICIAN ASSISTANTS | OTHER |