Provider Demographics
NPI:1558821843
Name:SHETLAR, LOGAN JOHN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:JOHN
Last Name:SHETLAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W NOBLE ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:KS
Mailing Address - Zip Code:67554-3026
Mailing Address - Country:US
Mailing Address - Phone:620-257-5124
Mailing Address - Fax:620-257-5128
Practice Address - Street 1:1221 W NOBLE ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:KS
Practice Address - Zip Code:67554-3026
Practice Address - Country:US
Practice Address - Phone:620-257-5124
Practice Address - Fax:620-257-5128
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS04-46362207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program