Provider Demographics
NPI:1891022604
Name:OWEN, MARK ALLAN (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLAN
Last Name:OWEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-2846
Mailing Address - Country:US
Mailing Address - Phone:270-825-0069
Mailing Address - Fax:270-824-9777
Practice Address - Street 1:444 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2846
Practice Address - Country:US
Practice Address - Phone:270-825-0069
Practice Address - Fax:270-824-9777
Is Sole Proprietor?:No
Enumeration Date:2009-11-16
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY000976225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3397798Medicare PIN