Healthcare Provider Details

I. General information

NPI: 1548450349
Provider Name (Legal Business Name): BRYAN L. LOGAN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 VILLAGE DRIVE
SPARTA MO
65673
US

IV. Provider business mailing address

PO BOX 183
SPARTA MO
65753-0183
US

V. Phone/Fax

Practice location:
  • Phone: 417-634-4203
  • Fax: 417-634-4505
Mailing address:
  • Phone: 417-634-4203
  • Fax: 417-634-4505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number127563
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: