Healthcare Provider Details

I. General information

NPI: 1780324038
Provider Name (Legal Business Name): LOGAN REX TAYSOM MD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N CAMPBELL AVE
TUCSON AZ
85719-4330
US

IV. Provider business mailing address

4025 W BORAS MINE CT
TUCSON AZ
85745-4196
US

V. Phone/Fax

Practice location:
  • Phone: 520-694-0111
  • Fax:
Mailing address:
  • Phone: 480-254-8690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number79111
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: