Provider Demographics
NPI:1902637069
Name:KOI, LOGAN MARK (PA-C)
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:MARK
Last Name:KOI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1611 W HARRISON ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:877-632-6637
Mailing Address - Fax:708-409-5179
Practice Address - Street 1:1611 W HARRISON ST STE 400
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:877-632-6637
Practice Address - Fax:708-409-5179
Is Sole Proprietor?:No
Enumeration Date:2024-08-12
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10004716A363A00000X
IL085011021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant