Provider Demographics
NPI:1336624089
Name:STEPHENS, LOGAN ALYSSA (PA)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:ALYSSA
Last Name:STEPHENS
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:LOGAN
Other - Middle Name:ALYSSA
Other - Last Name:RAULERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1824 KING ST STE 200
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4736
Mailing Address - Country:US
Mailing Address - Phone:904-384-3343
Mailing Address - Fax:904-400-6671
Practice Address - Street 1:3627 UNIVERSITY BLVD S STE 135
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4231
Practice Address - Country:US
Practice Address - Phone:904-398-8147
Practice Address - Fax:904-400-6674
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111646363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical