Healthcare Provider Details

I. General information

NPI: 1982080719
Provider Name (Legal Business Name): LOGAN COOK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 2ND ST
RICHLANDS VA
24641-2305
US

IV. Provider business mailing address

324 LAUREL CYN
JOHNSON CITY TN
37615-4778
US

V. Phone/Fax

Practice location:
  • Phone: 276-345-9900
  • Fax: 276-345-9901
Mailing address:
  • Phone: 423-782-6845
  • Fax: 423-461-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174236
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20243
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: