Provider Demographics
NPI:1619250826
Name:LOGAN, SHELBY FOX (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:FOX
Last Name:LOGAN
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 1:2780 E BARNETT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8674
Mailing Address - Country:US
Mailing Address - Phone:541-779-6250
Mailing Address - Fax:541-608-2535
Practice Address - Street 1:702 SW RAMSEY AVE STE 112
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5859
Practice Address - Country:US
Practice Address - Phone:541-472-0603
Practice Address - Fax:541-472-0609
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA205860363A00000X, 363A00000X
PA07566363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287118805Medicaid
TX287118804Medicaid
TX546024YL9XMedicare PIN
TX287118804Medicaid