Provider Demographics
NPI:1457900219
Name:LOGUE, DANA R (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:R
Last Name:LOGUE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E SHERMAN BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1854
Mailing Address - Country:US
Mailing Address - Phone:973-713-8539
Mailing Address - Fax:231-672-3973
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-672-3883
Practice Address - Fax:231-672-3973
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601009498363A00000X, 363A00000X
MI5601009498TMP19363A00000X
MI5601009498APP19363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant