Provider Demographics
NPI:1699965178
Name:OWEN, NICOLE ANASTASIA (PA-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANASTASIA
Last Name:OWEN
Suffix:
Gender:F
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 1:1163 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:MONONGAHELA
Mailing Address - State:PA
Mailing Address - Zip Code:15063-1013
Mailing Address - Country:US
Mailing Address - Phone:412-432-7400
Mailing Address - Fax:412-432-7480
Practice Address - Street 1:1163 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:MONONGAHELA
Practice Address - State:PA
Practice Address - Zip Code:15063-1013
Practice Address - Country:US
Practice Address - Phone:724-258-1841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical