Healthcare Provider Details

I. General information

NPI: 1053130898
Provider Name (Legal Business Name): RAQUEL IRIS LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAQUEL DIXON

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 MORSE AVE
SACRAMENTO CA
95825-2115
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-973-5000
  • Fax:
Mailing address:
  • Phone: 800-470-0071
  • Fax: 916-854-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number833266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: