Provider Demographics
NPI:1720887169
Name:ROLES, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:ROLES
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 1:1102 W MACARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1743
Mailing Address - Country:US
Mailing Address - Phone:405-273-2270
Mailing Address - Fax:
Practice Address - Street 1:1102 W MACARTHUR ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1743
Practice Address - Country:US
Practice Address - Phone:405-273-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant