Basic Information
| Provider Information | |||||||||
| NPI: | 1518024694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOWE | ||||||||
| FirstName: | KAIA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6572 RIVER PARK DR | ||||||||
| Address2: | #101 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709966699 | ||||||||
| FaxNumber: | 7706922669 | ||||||||
| Practice Location | |||||||||
| Address1: | 6572 RIVER PARK DR | ||||||||
| Address2: | #101 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709966699 | ||||||||
| FaxNumber: | 7706922669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363A00000X | 004319 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 004319 | 01 | GA | STATE LICENSE | OTHER |