Healthcare Provider Details

I. General information

NPI: 1144661752
Provider Name (Legal Business Name): LOGAN DANIEL CUTTS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2013
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE A205
IDAHO FALLS ID
83404-7586
US

IV. Provider business mailing address

PO BOX 277381
ATLANTA GA
30384-7381
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4580
  • Fax: 208-535-4520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1304A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: