Provider Demographics
NPI:1386012482
Name:LOGAN, SAMUEL (APN)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:847-690-1858
Mailing Address - Fax:
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-690-1858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277000181363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner