Provider Demographics
NPI:1699105304
Name:LOGAN, ROBERT JOSHUA (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JOSHUA
Last Name:LOGAN
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:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:613 23RD ST STE 140
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-326-1675
Practice Address - Fax:606-326-1436
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1630225X00000X
KYTC717363A00000X
OH50.006077RX363A00000X
WV2096363A00000X
KYPA2372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100515940Medicaid
OH0243582Medicaid