Healthcare Provider Details

I. General information

NPI: 1780107433
Provider Name (Legal Business Name): MARK ALAN LOGAN PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3596 W ALTAIR WAY
FLAGSTAFF AZ
86001-2075
US

IV. Provider business mailing address

3596 W ALTAIR WAY
FLAGSTAFF AZ
86001-2075
US

V. Phone/Fax

Practice location:
  • Phone: 913-634-1341
  • Fax:
Mailing address:
  • Phone: 913-634-1341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number316036
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: