Provider Demographics
NPI:1568128742
Name:ROBERTSON, LOGAN BROOKE (NP)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:BROOKE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:270 COPPERFIELD BLVD NE
Practice Address - Street 2:STE 102
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2441
Practice Address - Country:US
Practice Address - Phone:704-786-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015369363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner