Provider Demographics
NPI:1215697941
Name:KODYSZ, LOGAN (NP)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:KODYSZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 N 3RD ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1145
Mailing Address - Country:US
Mailing Address - Phone:602-492-2121
Mailing Address - Fax:602-354-9301
Practice Address - Street 1:2601 N 3RD ST STE 205
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1145
Practice Address - Country:US
Practice Address - Phone:602-492-2121
Practice Address - Fax:602-354-9301
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ268124363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health