Provider Demographics
NPI:1508516584
Name:HATTON, LOGAN DALE (PA-C)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:DALE
Last Name:HATTON
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 1:6553 E BAYWOOD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1753
Mailing Address - Country:US
Mailing Address - Phone:480-543-6750
Mailing Address - Fax:
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ10023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program