Provider Demographics
NPI:1508994104
Name:LOGAN, MARK J (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:LOGAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 PIPER ST
Mailing Address - Street 2:SUITE T300
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4624
Mailing Address - Country:US
Mailing Address - Phone:907-563-3103
Mailing Address - Fax:907-561-1862
Practice Address - Street 1:3841 PIPER ST
Practice Address - Street 2:SUITE T300
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4624
Practice Address - Country:US
Practice Address - Phone:907-563-3103
Practice Address - Fax:907-561-1862
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA05197363A00000X
AK965363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1039349Medicaid
AKMDA0383Medicaid
AKK163662Medicare PIN
LA57627P947Medicare PIN