Provider Demographics
NPI:1821162215
Name:LOGGINS, MARY SMALL (PA-C, MS)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SMALL
Last Name:LOGGINS
Suffix:
Gender:F
Credentials:PA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 BLANTON RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3620
Mailing Address - Country:US
Mailing Address - Phone:404-252-2554
Mailing Address - Fax:
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 850
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-252-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002287363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical