Provider Demographics
NPI:1376725697
Name:LOGAN, GINA (PAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 WASHINGTON ST
Mailing Address - Street 2:EIGHT TOWER BRIDGE, SUITE 1400
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2083
Mailing Address - Country:US
Mailing Address - Phone:866-825-3227
Mailing Address - Fax:484-450-2617
Practice Address - Street 1:7440 FM 1960 RD E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-3129
Practice Address - Country:US
Practice Address - Phone:866-325-3227
Practice Address - Fax:484-450-2617
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA02030OtherLICENSE