Provider Demographics
NPI:1073562807
Name:LOGAN, LINDA S (CRNA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:S
Last Name:LOGAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3622 BELMONT AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-1450
Mailing Address - Country:US
Mailing Address - Phone:330-759-9350
Mailing Address - Fax:330-759-9387
Practice Address - Street 1:3893 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-4706
Practice Address - Country:US
Practice Address - Phone:330-856-1272
Practice Address - Fax:330-856-2960
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-135649163W00000X
OHCOA.00492-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0847963Medicaid
OH11894927OtherCAQH
OH0847963Medicaid