Provider Demographics
NPI:1508463365
Name:MARTIN, LOGAN CURRAN (PA-C)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:CURRAN
Last Name:MARTIN
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 1:1700 SUMMER ST APT C92
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2396
Mailing Address - Country:US
Mailing Address - Phone:615-587-1436
Mailing Address - Fax:
Practice Address - Street 1:1211 DINAH SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37398-1107
Practice Address - Country:US
Practice Address - Phone:931-967-6669
Practice Address - Fax:931-967-6606
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ063418Medicaid