Provider Demographics
NPI:1114924222
Name:HYATT, LOGAN E (PA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:E
Last Name:HYATT
Suffix:
Gender:M
Credentials:PA
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 26194
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-2012
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:
Practice Address - Street 1:555 JUSTIS DR
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-4288
Practice Address - Country:US
Practice Address - Phone:423-254-6460
Practice Address - Fax:833-908-2070
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3711363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700C810580OtherBLUE CROSS OF MI
MIM95720020Medicare PIN
OHHUPA75521Medicare PIN