Provider Demographics
NPI:1043083280
Name:KNUTSON, LOGAN LEE
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:LEE
Last Name:KNUTSON
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:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:HERON LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56137-0281
Mailing Address - Country:US
Mailing Address - Phone:507-360-5051
Mailing Address - Fax:
Practice Address - Street 1:1132 5TH AVE
Practice Address - Street 2:
Practice Address - City:HERON LAKE
Practice Address - State:MN
Practice Address - Zip Code:56137-4038
Practice Address - Country:US
Practice Address - Phone:507-360-5051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program