MEDICARE: MR. JON ANDREW LOGAN RPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2471C3401X	Computed Tomography Radiologic Technologist	309371	GA
2	363A00000X	Physician Assistant	06WI1204	GA

General Provider Information

NPI Number	:	1215133038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON ANDREW LOGAN RPA

Provider Business Mailing Address
First Line	:	214 SUTTON RD
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-2221
Country	:	US
Telephone Number	:	229-382-2827
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 NORTH AVE
Second Line	:	STE. C-30
City	:	ATLANTA
State	:	GA
Zip	:	30354-1430
Country	:	US
Telephone Number	:	678-904-6820
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	09/11/2025

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