Provider Demographics
NPI:1306817259
Name:LOGAN, CYNTHIA A (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
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 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5698
Mailing Address - Fax:828-650-8076
Practice Address - Street 1:125 VANCE HILL DR
Practice Address - Street 2:
Practice Address - City:MILLS RIVER
Practice Address - State:NC
Practice Address - Zip Code:28759
Practice Address - Country:US
Practice Address - Phone:828-891-7522
Practice Address - Fax:828-891-7523
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222161207Q00000X
NC2016-01589207Q00000X
TN42113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1306817259Medicaid
VAP01081173OtherRR MEDICARE
TN3000080Medicaid
VAVV3843AMedicare PIN
TN3000080Medicaid
TN3709285Medicare UPIN
VAP01081173OtherRR MEDICARE
TN3709285Medicare UPIN
TN3000080Medicaid