Provider Demographics
NPI:1174097448
Name:OWENS, MARIO ANTWAN (NP)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:ANTWAN
Last Name:OWENS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 SERENE WAY
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-5153
Mailing Address - Country:US
Mailing Address - Phone:678-215-9947
Mailing Address - Fax:
Practice Address - Street 1:5665 PEACHTREE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1764
Practice Address - Country:US
Practice Address - Phone:678-843-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-19
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF01190896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily