Provider Demographics
NPI:1215384219
Name:LOGAN, CORY ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:ALAN
Last Name:LOGAN
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 1:1615 HOSPITAL PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-5935
Mailing Address - Country:US
Mailing Address - Phone:817-354-2680
Mailing Address - Fax:817-510-5927
Practice Address - Street 1:1615 HOSPITAL PKWY STE 103
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-5935
Practice Address - Country:US
Practice Address - Phone:817-354-2680
Practice Address - Fax:817-510-5927
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX514229YKPWMedicare PIN