Provider Demographics
NPI:1417058215
Name:LOWE, NANETTA BONITA (MD)
Entity Type:Individual
Prefix:DR
First Name:NANETTA
Middle Name:BONITA
Last Name:LOWE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NANETTA
Other - Middle Name:BONITA
Other - Last Name:LOWE-ROACHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1250 B CAMELOT DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4677
Mailing Address - Country:US
Mailing Address - Phone:918-453-0464
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-458-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC66579207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC50253NMedicare UPIN