Provider Demographics
NPI:1750468294
Name:LOGAN, IRENE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:EAST MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11940-1225
Mailing Address - Country:US
Mailing Address - Phone:631-874-2900
Mailing Address - Fax:631-874-2948
Practice Address - Street 1:516 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:EAST MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11940-1225
Practice Address - Country:US
Practice Address - Phone:631-874-2900
Practice Address - Fax:631-874-2948
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF301015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS77256Medicare UPIN
NY90N011Medicare ID - Type Unspecified