Basic Information
| Provider Information | |||||||||
| NPI: | 1821046392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | BRET | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16620 COBBLESTONE CIR | ||||||||
| Address2: | |||||||||
| City: | CHOCTAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730206953 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2825 PARKLAWN DR | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731104201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056104411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 03/16/2015 | ||||||||
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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 | PA819 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100113210A | 05 | OK | MEDICAID |