Provider Demographics
NPI:1073752085
Name:LOGSTON, BRADLEY J (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:J
Last Name:LOGSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9613 SANDIFUR PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8028
Mailing Address - Country:US
Mailing Address - Phone:509-943-8839
Mailing Address - Fax:509-943-8851
Practice Address - Street 1:9613 SANDIFUR PKWY STE A
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8028
Practice Address - Country:US
Practice Address - Phone:509-943-8839
Practice Address - Fax:509-943-8851
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60219543207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040768Medicaid