Provider Demographics
NPI:1053173427
Name:OWEIMRIN, AUDREY KINNEAR (PA-C)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:KINNEAR
Last Name:OWEIMRIN
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 1:342 N MAIN ST STE 350
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-2530
Mailing Address - Country:US
Mailing Address - Phone:860-296-4022
Mailing Address - Fax:
Practice Address - Street 1:342 N MAIN ST STE 350
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-2530
Practice Address - Country:US
Practice Address - Phone:860-296-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant