Provider Demographics
NPI:1962553347
Name:LOGUE, REBECCA M (ANP)
Entity type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:M
Last Name:LOGUE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 47090
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85068-7090
Mailing Address - Country:US
Mailing Address - Phone:623-934-5600
Mailing Address - Fax:623-934-5603
Practice Address - Street 1:14973 W BELL RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3236
Practice Address - Country:US
Practice Address - Phone:623-934-5600
Practice Address - Fax:623-934-5603
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1554363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ746547Medicaid
AZP83534Medicare UPIN
AZ101335Medicare ID - Type Unspecified