Healthcare Provider Details

I. General information

NPI: 1841627445
Provider Name (Legal Business Name): LOGAN MITCHELL SHOLLEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 NORTHPARK DR
KINGWOOD TX
77339-1636
US

IV. Provider business mailing address

1331 NORTHPARK DR
KINGWOOD TX
77339-1636
US

V. Phone/Fax

Practice location:
  • Phone: 281-359-5330
  • Fax:
Mailing address:
  • Phone: 281-359-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09212
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC05225
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: