Basic Information
Provider Information | |||||||||
NPI: | 1417058215 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOWE | ||||||||
FirstName: | NANETTA | ||||||||
MiddleName: | BONITA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOWE-ROACHE | ||||||||
OtherFirstName: | NANETTA | ||||||||
OtherMiddleName: | BONITA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1250 B CAMELOT DRIVE | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744644677 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184530464 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 S BLISS AVE | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 74464 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184583100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 66579 | NC | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.