Provider Demographics
NPI:1629676812
Name:LOGAN, TYLER A
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:A
Last Name:LOGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3251 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-1702
Mailing Address - Country:US
Mailing Address - Phone:133-098-0582
Mailing Address - Fax:
Practice Address - Street 1:3251 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-1702
Practice Address - Country:US
Practice Address - Phone:330-980-5820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-11
Last Update Date:2020-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health