Provider Demographics
NPI:1497141527
Name:JOHNSON, LOGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
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 743752
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10652 S EASTERN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4952
Practice Address - Country:US
Practice Address - Phone:702-476-2800
Practice Address - Fax:702-476-2040
Is Sole Proprietor?:No
Enumeration Date:2015-04-15
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA0313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant