Provider Demographics
NPI:1104211101
Name:NAGEL, LOGAN (ATC/L)
Entity type:Individual
Prefix:MR
First Name:LOGAN
Middle Name:
Last Name:NAGEL
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 BEATRICE LN
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-7834
Mailing Address - Country:US
Mailing Address - Phone:567-224-5447
Mailing Address - Fax:
Practice Address - Street 1:1815 WELLS ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003-1304
Practice Address - Country:US
Practice Address - Phone:575-646-7574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM572OtherSTATE OF NEW MEXICO REGULATIONS & LICENSING DEPARTMENT ATHLETIC TRAINERS PRACTIC
OH2000012918OtherBOARD OF CERTIFICATION OF ATHLETIC TRAINING