Basic Information
| Provider Information | |||||||||
| NPI: | 1023014438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOWE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9855 HOSPITAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635819220 | ||||||||
| FaxNumber: | 7635819221 | ||||||||
| Practice Location | |||||||||
| Address1: | 9855 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635819220 | ||||||||
| FaxNumber: | 7635819221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 08/30/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | BL6168442 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 036101859 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54499 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 080172806 | 01 | IL | RR MEDICARE | OTHER | 441397 | 01 | HEALTHLINK | OTHER | 036101859 | 05 | IL | MEDICAID | 38398 | 01 | GROUP HEALTH PLAN | OTHER | 0100970 | 01 | UNITED HEALTHCARE | OTHER | 1023014438 | 05 | MO | MEDICAID | 4622029 | 01 | IL | ADMINISTAR | OTHER | 036101859-3 | 05 | IL | MEDICAID |