Healthcare Provider Details

I. General information

NPI: 1619346269
Provider Name (Legal Business Name): LOGAN MICHAELINE KWASNICKA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LOGAN ROCK PA-C

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 07/09/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 SHARON COPLEY RD
WADSWORTH OH
44281
US

IV. Provider business mailing address

PO BOX 62
SHARON CENTER OH
44274-0062
US

V. Phone/Fax

Practice location:
  • Phone: 330-591-2444
  • Fax: 833-740-3510
Mailing address:
  • Phone: 724-815-8511
  • Fax: 833-740-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004463
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: