Healthcare Provider Details

I. General information

NPI: 1508516584
Provider Name (Legal Business Name): LOGAN DALE HATTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

6553 E BAYWOOD AVE STE 101
MESA AZ
85206-1753
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-1250
  • Fax:
Mailing address:
  • Phone: 480-543-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10023
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: