Provider Demographics
NPI:1104895234
Name:OWENS, ROGER K (PA-C)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:K
Last Name:OWENS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 KENTON STATION DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9609
Mailing Address - Country:US
Mailing Address - Phone:606-759-9353
Mailing Address - Fax:606-759-0493
Practice Address - Street 1:169 MEDICAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:FLEMINGSBURG
Practice Address - State:KY
Practice Address - Zip Code:41041
Practice Address - Country:US
Practice Address - Phone:606-849-2675
Practice Address - Fax:606-849-2658
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA-084363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500533600Medicaid
KY6293OtherKY MEDICARE GROUP #
KYR38988Medicare UPIN
KY6293OtherKY MEDICARE GROUP #