Provider Demographics
NPI:1982080719
Name:COOK, LOGAN (FNP)
Entity Type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 PAVILION DR
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4641
Mailing Address - Country:US
Mailing Address - Phone:423-857-7650
Mailing Address - Fax:423-857-7655
Practice Address - Street 1:2205 PAVILION DR
Practice Address - Street 2:SUITE 201B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4641
Practice Address - Country:US
Practice Address - Phone:423-857-7650
Practice Address - Fax:423-857-7655
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174236363LF0000X
TN20243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982080719Medicaid
TNQ016246Medicaid
TNQ016246Medicaid
TN10350I1040Medicare PIN