Provider Demographics
NPI:1356053094
Name:LOWE, GRACE CAROLYN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:CAROLYN
Last Name:LOWE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 SE SIDONIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4901
Mailing Address - Country:US
Mailing Address - Phone:813-373-9975
Mailing Address - Fax:
Practice Address - Street 1:3573 SW CORPORATE PKWY
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-8153
Practice Address - Country:US
Practice Address - Phone:772-283-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116845208000000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics