Provider Demographics
NPI:1386352185
Name:LOCKWOOD, LOGAN NICOLE
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:NICOLE
Last Name:LOCKWOOD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1229
Mailing Address - Country:US
Mailing Address - Phone:336-663-5220
Mailing Address - Fax:
Practice Address - Street 1:1126 N CHURCH ST STE 300
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1037
Practice Address - Country:US
Practice Address - Phone:336-938-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001015111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty