Provider Demographics
NPI:1093343402
Name:ROBERTSON, LOGAN HARRISON
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:HARRISON
Last Name:ROBERTSON
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 1:11110 MEDICAL CAMPUS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6797
Mailing Address - Country:US
Mailing Address - Phone:301-714-4400
Mailing Address - Fax:
Practice Address - Street 1:11110 MEDICAL CAMPUS RD STE 200
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6797
Practice Address - Country:US
Practice Address - Phone:301-714-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC08038363A00000X
390200000X
MDC0008038363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program