Healthcare Provider Details

I. General information

NPI: 1003146226
Provider Name (Legal Business Name): DUSTIN ALLEN LOGUE ANP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2010
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 PLANK RD
BAKER LA
70714-4911
US

IV. Provider business mailing address

12902 PLANK RD
BAKER LA
70714-4911
US

V. Phone/Fax

Practice location:
  • Phone: 225-369-7006
  • Fax: 225-774-2827
Mailing address:
  • Phone: 225-774-0733
  • Fax: 225-774-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number06078
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: