Provider Demographics
NPI:1023051018
Name:LOGUE, CINDY W (PA)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:W
Last Name:LOGUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:M
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5800 OVERSEAS HWY STE 38
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:FL
Mailing Address - Zip Code:33050-2744
Mailing Address - Country:US
Mailing Address - Phone:936-718-5006
Mailing Address - Fax:
Practice Address - Street 1:2100 FLAGLER AVE
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040
Practice Address - Country:US
Practice Address - Phone:305-293-1549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102429363A00000X
TXPA03791363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L9187OtherPTAN
FL102130600Medicaid
TX8N7773OtherBCBS
TX8L9188OtherPTAN
TX8L9190OtherPTAN
TX00N38NOtherPTAN
TX00N38NOtherPTAN
TX8L9187OtherPTAN
TX8L3423Medicare PIN