Provider Demographics
NPI:1508148677
Name:LOWTHER, KENNETH RAY (FNP-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAY
Last Name:LOWTHER
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 BERRYMAN RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5572
Mailing Address - Country:US
Mailing Address - Phone:208-221-6121
Mailing Address - Fax:888-798-7346
Practice Address - Street 1:965 BERRYMAN RD
Practice Address - Street 2:UNIT A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5572
Practice Address - Country:US
Practice Address - Phone:208-221-6121
Practice Address - Fax:888-798-7346
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1104A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily