Healthcare Provider Details

I. General information

NPI: 1902949951
Provider Name (Legal Business Name): PK LOGAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 LAGUNA RD
FULLERTON CA
92835-3614
US

IV. Provider business mailing address

832 SUNSET DR
HERMOSA BEACH CA
90254-4248
US

V. Phone/Fax

Practice location:
  • Phone: 714-447-4800
  • Fax: 714-447-1098
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA12280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: