Provider Demographics
NPI:1699231019
Name:LOGAN, MARSHALL JR (NP-C)
Entity type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:
Last Name:LOGAN
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 N HIGHLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4565
Mailing Address - Country:US
Mailing Address - Phone:404-733-6089
Mailing Address - Fax:
Practice Address - Street 1:865 N HIGHLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4565
Practice Address - Country:US
Practice Address - Phone:404-733-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA214743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily