Provider Demographics
NPI:1396893400
Name:LOGAN, BERNARD A JR (PA)
Entity type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:A
Last Name:LOGAN
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 LAKE TO LAKE RD
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14561-9757
Mailing Address - Country:US
Mailing Address - Phone:585-727-3656
Mailing Address - Fax:
Practice Address - Street 1:350 PARRISH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1731
Practice Address - Country:US
Practice Address - Phone:585-396-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001368363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical