Provider Demographics
NPI:1497362438
Name:WERTZ, LOGANNE D (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LOGANNE
Middle Name:D
Last Name:WERTZ
Suffix:
Gender:F
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 1:905 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:FOWLER
Mailing Address - State:IN
Mailing Address - Zip Code:47944-1620
Mailing Address - Country:US
Mailing Address - Phone:574-870-9659
Mailing Address - Fax:
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1019
Practice Address - Country:US
Practice Address - Phone:812-242-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant