Provider Demographics
NPI:1346061116
Name:BUSH, LOGAN (PTA)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:BUSH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 SHADOWLAKE RD
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6877
Mailing Address - Country:US
Mailing Address - Phone:918-457-7521
Mailing Address - Fax:
Practice Address - Street 1:9210 S WESTERN AVE STE 27
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2734
Practice Address - Country:US
Practice Address - Phone:405-692-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3857225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant