Provider Demographics
NPI:1104688803
Name:MANN, LOGAN JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:JACOB
Last Name:MANN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5048 PADDOCK LOOP
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40342-1735
Mailing Address - Country:US
Mailing Address - Phone:502-598-1024
Mailing Address - Fax:
Practice Address - Street 1:175 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-9591
Practice Address - Country:US
Practice Address - Phone:859-745-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant