Healthcare Provider Details

I. General information

NPI: 1538902481
Provider Name (Legal Business Name): LOGAN MCINTIRE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 RYAN DR SE
SALEM OR
97301-9687
US

IV. Provider business mailing address

PO BOX 12989
SALEM OR
97309-0989
US

V. Phone/Fax

Practice location:
  • Phone: 503-399-1262
  • Fax:
Mailing address:
  • Phone: 503-399-1262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA227644
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberPA227644
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: