Provider Demographics
NPI:1396381695
Name:MATHEWS, LOGAN PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:PATRICK
Last Name:MATHEWS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16152 GILLS NECK RD
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-5029
Mailing Address - Country:US
Mailing Address - Phone:302-841-1375
Mailing Address - Fax:
Practice Address - Street 1:424 SAVANNAH RD
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958
Practice Address - Country:US
Practice Address - Phone:302-294-1468
Practice Address - Fax:302-261-7399
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001371363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant