Healthcare Provider Details

I. General information

NPI: 1659878437
Provider Name (Legal Business Name): LOGAN BUSHNELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LILLY RD NE STE 100
OLYMPIA WA
98506-5117
US

IV. Provider business mailing address

PO BOX 368
OLYMPIA WA
98507-0368
US

V. Phone/Fax

Practice location:
  • Phone: 360-491-4211
  • Fax:
Mailing address:
  • Phone: 360-491-8439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberOP61480077
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOP61480077
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: