Healthcare Provider Details

I. General information

NPI: 1447609300
Provider Name (Legal Business Name): LOGAN J KOPF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PERSHING AVE
SHENANDOAH IA
51601-2355
US

IV. Provider business mailing address

300 PERSHING AVE
SHENANDOAH IA
51601-2355
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-7106
  • Fax: 712-246-7357
Mailing address:
  • Phone: 712-246-7106
  • Fax: 712-246-7357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD144014
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: