Provider Demographics
NPI:1003146226
Name:LOGUE, DUSTIN ALLEN (ANP)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:ALLEN
Last Name:LOGUE
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:LA
Mailing Address - Zip Code:70714-4911
Mailing Address - Country:US
Mailing Address - Phone:225-369-7006
Mailing Address - Fax:225-774-2827
Practice Address - Street 1:12902 PLANK RD
Practice Address - Street 2:
Practice Address - City:BAKER
Practice Address - State:LA
Practice Address - Zip Code:70714-4911
Practice Address - Country:US
Practice Address - Phone:225-369-7006
Practice Address - Fax:225-774-2827
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06078363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2110691Medicaid
LA3B7386833Medicare PIN