Provider Demographics
NPI:1134825060
Name:RATTS, LOGAN (PA-C)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:RATTS
Suffix:
Gender:
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 1:240 N WICKHAM RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8663
Mailing Address - Country:US
Mailing Address - Phone:321-541-1777
Mailing Address - Fax:321-541-1787
Practice Address - Street 1:240 N WICKHAM RD STE 102
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8663
Practice Address - Country:US
Practice Address - Phone:321-541-1777
Practice Address - Fax:321-541-1787
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9117936363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120194100Medicaid