Healthcare Provider Details

I. General information

NPI: 1144013657
Provider Name (Legal Business Name): LOGAN GLENN LOVELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 WESTERN BLVD
JACKSONVILLE NC
28546-6338
US

IV. Provider business mailing address

10605 KETTERING DR APT 1013
CHARLOTTE NC
28226-4776
US

V. Phone/Fax

Practice location:
  • Phone: 910-577-2345
  • Fax:
Mailing address:
  • Phone: 843-504-4166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: