Provider Demographics
NPI:1720528805
Name:CRIST, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:CRIST
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 1:100 PMC DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEEKER
Mailing Address - State:CO
Mailing Address - Zip Code:81641
Mailing Address - Country:US
Mailing Address - Phone:970-987-8125
Mailing Address - Fax:
Practice Address - Street 1:100 PMC DR
Practice Address - Street 2:
Practice Address - City:MEEKER
Practice Address - State:CO
Practice Address - Zip Code:81641-3181
Practice Address - Country:US
Practice Address - Phone:970-987-8125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO87-0788731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant