Provider Demographics
NPI:1306494976
Name:TUTTLE, LOGAN (PA)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:TUTTLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 FIELD ST APT D253
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1991
Mailing Address - Country:US
Mailing Address - Phone:435-609-3153
Mailing Address - Fax:
Practice Address - Street 1:1267 HIGHWAY 54 W STE 2200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2110
Practice Address - Country:US
Practice Address - Phone:770-716-0051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10968363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program