Healthcare Provider Details

I. General information

NPI: 1740796994
Provider Name (Legal Business Name): LOGAN ASTON PONCE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 GRIER DR
LAS VEGAS NV
89119-3701
US

IV. Provider business mailing address

1720 FOREST WALK DR
LAS VEGAS NV
89119-4539
US

V. Phone/Fax

Practice location:
  • Phone: 702-352-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number4437
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number294086
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number4437
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: