Provider Demographics
NPI:1215133038
Name:LOGAN, JON ANDREW (RPA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:ANDREW
Last Name:LOGAN
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:214 SUTTON RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2221
Mailing Address - Country:US
Mailing Address - Phone:229-382-2827
Mailing Address - Fax:
Practice Address - Street 1:621 NORTH AVE
Practice Address - Street 2:STE. C-30
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30354-1430
Practice Address - Country:US
Practice Address - Phone:678-904-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3093712471C3401X
GA06WI1204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant