Provider Demographics
NPI:1114615382
Name:SMITH, LOGAN THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8015 S COOPER ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-7018
Mailing Address - Country:US
Mailing Address - Phone:817-453-4440
Mailing Address - Fax:
Practice Address - Street 1:8015 S COOPER ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-7018
Practice Address - Country:US
Practice Address - Phone:817-453-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant