Provider Demographics
NPI:1609639558
Name:BOYER, LOGAN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:BOYER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:101 BRIARS DR APT 703
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6119
Mailing Address - Country:US
Mailing Address - Phone:570-765-8697
Mailing Address - Fax:
Practice Address - Street 1:1190 N STATE ST STE 502
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2414
Practice Address - Country:US
Practice Address - Phone:601-944-1781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical