Healthcare Provider Details

I. General information

NPI: 1154870145
Provider Name (Legal Business Name): YEN LOGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2016
Last Update Date: 10/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14139 POTOMAC MILLS RD
WOODBRIDGE VA
22192-4644
US

IV. Provider business mailing address

14139 POTOMAC MILLS RD
WOODBRIDGE VA
22192-4644
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-8400
  • Fax:
Mailing address:
  • Phone: 703-490-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number0202205698
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: