Provider Demographics
NPI:1356496079
Name:KING-LOGSDON, NEVRA SISLI (MD)
Entity Type:Individual
Prefix:DR
First Name:NEVRA
Middle Name:SISLI
Last Name:KING-LOGSDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NEVRA
Other - Middle Name:S
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:8234 E PALM LN
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-9713
Mailing Address - Country:US
Mailing Address - Phone:480-381-7669
Mailing Address - Fax:
Practice Address - Street 1:1520 S DOBSON RD
Practice Address - Street 2:SUITE 203
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4725
Practice Address - Country:US
Practice Address - Phone:480-412-8080
Practice Address - Fax:480-412-6999
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1368171000000X
NC2009-00154171000000X
PAMD429270207T00000X
AZ44030207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM131011OtherNEUROSURGERY RESIDENT
AZZ143986Medicare PIN