Provider Demographics
NPI:1184353302
Name:ODERIO, LOGAN TERYN (PA-C)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:TERYN
Last Name:ODERIO
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:TERYN
Other - Last Name:PETTIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-993-4656
Mailing Address - Fax:515-993-4532
Practice Address - Street 1:1120 GREENE ST
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:IA
Practice Address - Zip Code:50003-1712
Practice Address - Country:US
Practice Address - Phone:515-993-4656
Practice Address - Fax:515-993-4532
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122340363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant