Healthcare Provider Details

I. General information

NPI: 1245055763
Provider Name (Legal Business Name): LOGAN ALEXANDER SIEMERS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17241 MURPHY AVE
IRVINE CA
92614-5917
US

IV. Provider business mailing address

18428 OAK CANYON RD APT 574
CANYON COUNTRY CA
91387-6358
US

V. Phone/Fax

Practice location:
  • Phone: 530-559-9246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number306509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: