Provider Demographics
NPI:1659650315
Name:RICH, LOGAN M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LOGAN
Middle Name:M
Last Name:RICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7500 RIALTO BLVD STE 1-140
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8534
Mailing Address - Country:US
Mailing Address - Phone:512-730-3060
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4705
Practice Address - Country:US
Practice Address - Phone:512-730-3060
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEPA001289363AM0700X
RIPA00771363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIU400260826Medicare PIN