Provider Demographics
NPI:1982186276
Name:DONEVANT, LOGAN (CAA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:DONEVANT
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5719 PICKENS AVE
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-2223
Mailing Address - Country:US
Mailing Address - Phone:843-360-9923
Mailing Address - Fax:
Practice Address - Street 1:11705 MERCY BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1711
Practice Address - Country:US
Practice Address - Phone:912-819-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8994367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant