Provider Demographics
NPI:1720678600
Name:AUSTIN, LOGAN JAMES
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:JAMES
Last Name:AUSTIN
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 1:151 BLUERIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-4227
Mailing Address - Country:US
Mailing Address - Phone:304-910-6182
Mailing Address - Fax:
Practice Address - Street 1:151 BLUERIDGE AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-4227
Practice Address - Country:US
Practice Address - Phone:304-910-6182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program