Healthcare Provider Details

I. General information

NPI: 1417309824
Provider Name (Legal Business Name): RICKEY LOGAN JR. PNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

550 1ST AVE
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 513-706-8109
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number382652
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: