Provider Demographics
NPI:1932642964
Name:ANDERSON, LOGAN GREGORY (PTA)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:GREGORY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8337 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-8231
Mailing Address - Country:US
Mailing Address - Phone:712-260-9425
Mailing Address - Fax:
Practice Address - Street 1:8900 PARALLEL PKWY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-1637
Practice Address - Country:US
Practice Address - Phone:913-788-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014011829225200000X
KS14-02983225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant