Provider Demographics
NPI:1154593275
Name:CLARK, LOGAN S (PA-C)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:S
Last Name:CLARK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3336 PIONEER PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2000
Mailing Address - Country:US
Mailing Address - Phone:801-250-9638
Mailing Address - Fax:801-417-0063
Practice Address - Street 1:8211 W 3500 S
Practice Address - Street 2:
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-1851
Practice Address - Country:US
Practice Address - Phone:801-250-9638
Practice Address - Fax:801-250-3204
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5262016-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant