Healthcare Provider Details

I. General information

NPI: 1215133038
Provider Name (Legal Business Name): JON ANDREW LOGAN RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 NORTH AVE STE. C-30
ATLANTA GA
30354-1430
US

IV. Provider business mailing address

214 SUTTON RD
TIFTON GA
31794-2221
US

V. Phone/Fax

Practice location:
  • Phone: 678-904-6820
  • Fax:
Mailing address:
  • Phone: 229-382-2827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number06WI1204
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2471C3401X
TaxonomyComputed Tomography Radiologic Technologist
License Number309371
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: