Provider Demographics
NPI:1023014438
Name:LOWE, NICOLE T (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:T
Last Name:LOWE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9855 HOSPITAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369
Mailing Address - Country:US
Mailing Address - Phone:763-581-9220
Mailing Address - Fax:763-581-9221
Practice Address - Street 1:9855 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4648
Practice Address - Country:US
Practice Address - Phone:763-581-9220
Practice Address - Fax:763-581-9221
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBL6168442207P00000X
IL036101859207Q00000X
MN54499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080172806OtherRR MEDICARE
441397OtherHEALTHLINK
IL036101859Medicaid
38398OtherGROUP HEALTH PLAN
0100970OtherUNITED HEALTHCARE
MO1023014438Medicaid
IL4622029OtherADMINISTAR
IL036101859-3Medicaid
IL080172806OtherRR MEDICARE
MO1023014438Medicaid
37-1205888OtherTAX ID NUMBER
IL036101859-3Medicaid