Provider Demographics
NPI:1154196798
Name:MA, NIA LOGAN (DNP, CRNA)
Entity type:Individual
Prefix:MRS
First Name:NIA
Middle Name:LOGAN
Last Name:MA
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:MISS
Other - First Name:NIA
Other - Middle Name:LOGAN
Other - Last Name:BOURNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3824 E SHEILA LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3665
Mailing Address - Country:US
Mailing Address - Phone:443-820-5662
Mailing Address - Fax:
Practice Address - Street 1:9003 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6709
Practice Address - Country:US
Practice Address - Phone:480-323-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ149835367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered