Provider Demographics
NPI:1770231474
Name:LOGAN, DANTE
Entity Type:Individual
Prefix:MR
First Name:DANTE
Middle Name:
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 1:1 CAMINO DEL SOL
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-5706
Mailing Address - Country:US
Mailing Address - Phone:505-610-1301
Mailing Address - Fax:
Practice Address - Street 1:1 CAMINO DEL SOL
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-5706
Practice Address - Country:US
Practice Address - Phone:505-610-1301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN-73242163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health