Provider Demographics
NPI:1851763619
Name:NOCERINO, LOGAN NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:NICHOLAS
Last Name:NOCERINO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:602-633-3841
Practice Address - Street 1:111 W CEDAR LN STE A
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5417
Practice Address - Country:US
Practice Address - Phone:623-512-4190
Practice Address - Fax:623-512-4194
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant