Provider Demographics
NPI:1427411651
Name:MIMS, LOGAN (MD)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:MIMS
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 1:605 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1873
Mailing Address - Country:US
Mailing Address - Phone:509-765-0674
Mailing Address - Fax:
Practice Address - Street 1:605 S COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1873
Practice Address - Country:US
Practice Address - Phone:509-765-0674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0062186207Q00000X
WAMD61113448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine