Provider Demographics
NPI:1144680026
Name:LO, KOU
Entity type:Individual
Prefix:
First Name:KOU
Middle Name:
Last Name:LO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 WOODSHIVE DR
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7925 WOODSHIVE DR
Practice Address - Street 2:
Practice Address - City:MABELVALE
Practice Address - State:AR
Practice Address - Zip Code:72103-2903
Practice Address - Country:US
Practice Address - Phone:501-940-1889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR80451367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered