Healthcare Provider Details

I. General information

NPI: 1205548864
Provider Name (Legal Business Name): LOGAN HAYES WEATHERFORD NEURPHYSIOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18761 CHESTNUT CT
MOKENA IL
60448-9501
US

IV. Provider business mailing address

7455 W WASHINGTON AVE STE 302
LAS VEGAS NV
89128-4340
US

V. Phone/Fax

Practice location:
  • Phone: 786-448-9020
  • Fax:
Mailing address:
  • Phone: 217-649-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number26-237
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number26-237
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: