Provider Demographics
NPI:1699752089
Name:LOGAN, KATHLEEN M (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:LOGAN
Suffix:
Gender:F
Credentials:MD
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 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-4818
Mailing Address - Fax:888-329-5701
Practice Address - Street 1:555 E BROADWAY AVE STE 204
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-4818
Practice Address - Fax:888-329-5701
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN253582084P0800X
WY11343A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY150491600Medicaid
MN237717900Medicaid
WI35207600Medicaid
WI35207600Medicaid
MN260002028Medicare PIN
MN260003145Medicare PIN
IAENROLLEDMedicaid