Provider Demographics
NPI:1245040856
Name:COLBAUGH, LOGAN BRYANT
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:BRYANT
Last Name:COLBAUGH
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 1:344 OLD MCCLURE RD SE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37323-8340
Mailing Address - Country:US
Mailing Address - Phone:423-464-1413
Mailing Address - Fax:
Practice Address - Street 1:615 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2504
Practice Address - Country:US
Practice Address - Phone:423-425-1741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000253901163W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse