Provider Demographics
NPI:1740708676
Name:LOGAN, LAZEDRICK (NP)
Entity type:Individual
Prefix:
First Name:LAZEDRICK
Middle Name:
Last Name:LOGAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 N CENTRAL EXPY STE 900
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2120
Mailing Address - Country:US
Mailing Address - Phone:800-909-7140
Mailing Address - Fax:
Practice Address - Street 1:4131 N CENTRAL EXPY STE 900
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2120
Practice Address - Country:US
Practice Address - Phone:800-909-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA829535163WP0808X
TX1032186163WP0808X, 363LP0808X
CA95008515363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner