Provider Demographics
NPI:1922653484
Name:NUNBERG, LOGEN ROSS (NP-C)
Entity Type:Individual
Prefix:
First Name:LOGEN
Middle Name:ROSS
Last Name:NUNBERG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 E OAK ST STE 1E
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-2978
Mailing Address - Country:US
Mailing Address - Phone:406-404-1350
Mailing Address - Fax:
Practice Address - Street 1:105 E OAK ST STE 1E
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2978
Practice Address - Country:US
Practice Address - Phone:406-404-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-146080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTNUR-APRN-LIC-146080OtherSTATE LICENSE