Provider Demographics
NPI:1689304024
Name:HOREJSI, LOGAN (PA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:HOREJSI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2685 RIPPLE CT
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48383-3277
Mailing Address - Country:US
Mailing Address - Phone:248-425-8436
Mailing Address - Fax:
Practice Address - Street 1:1500 PALMA DR STE 187
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6451
Practice Address - Country:US
Practice Address - Phone:805-222-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62015363A00000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program