Healthcare Provider Details

I. General information

NPI: 1720887169
Provider Name (Legal Business Name): LOGAN ROLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 BROADWAY EXT STE 203
OKLAHOMA CITY OK
73114-6304
US

IV. Provider business mailing address

9800 BROADWAY EXT STE 203
OKLAHOMA CITY OK
73114-6304
US

V. Phone/Fax

Practice location:
  • Phone: 405-424-5426
  • Fax:
Mailing address:
  • Phone: 405-424-5426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5576
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: