Healthcare Provider Details

I. General information

NPI: 1538521620
Provider Name (Legal Business Name): ZACHARY LOGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6843 E MAIN ST
MESA AZ
85207-8207
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 600
NASHVILLE TN
37205-5250
US

V. Phone/Fax

Practice location:
  • Phone: 480-870-7300
  • Fax: 480-870-7302
Mailing address:
  • Phone: 615-315-5257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number59949
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number67357
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: