Provider Demographics
NPI:1962030189
Name:LOGAN, RYAN WILLIAM
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WILLIAM
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 1:1250 LINCOLN RD APT 504
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-2255
Mailing Address - Country:US
Mailing Address - Phone:786-389-0977
Mailing Address - Fax:
Practice Address - Street 1:1250 LINCOLN RD APT 504
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-2255
Practice Address - Country:US
Practice Address - Phone:786-389-0977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant