Provider Demographics
NPI:1578987541
Name:ANDERSON, LOGAN FAYE
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:FAYE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7422 COUNTY ROAD 1480
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0531
Mailing Address - Country:US
Mailing Address - Phone:580-279-3376
Mailing Address - Fax:
Practice Address - Street 1:7422 COUNTY ROAD 1480
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-0531
Practice Address - Country:US
Practice Address - Phone:580-279-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program