Provider Demographics
NPI:1558944827
Name:LANGLEY, LOGAN G (PA-C)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:G
Last Name:LANGLEY
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 1:224 NW CRANE AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-1400
Mailing Address - Country:US
Mailing Address - Phone:850-253-1917
Mailing Address - Fax:
Practice Address - Street 1:224 NW CRANE AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:FL
Practice Address - Zip Code:32340-1400
Practice Address - Country:US
Practice Address - Phone:850-253-1917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9114280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant