Provider Demographics
NPI:1154902716
Name:LOGAN, MELANIE (PA-C)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:LOGAN
Suffix:
Gender:F
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 1:8130 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-2506
Mailing Address - Country:US
Mailing Address - Phone:614-448-6817
Mailing Address - Fax:
Practice Address - Street 1:5600 S QUEBEC ST STE 312A
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2208
Practice Address - Country:US
Practice Address - Phone:303-436-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006840363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant