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General NPI Number Information
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NPI Number | 1306494976
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Entity Type | Individual
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Provider Name | LOGAN TUTTLE PA
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Gender | Male
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Dates
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Enumeration Date | 08/27/2019
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Last Update Date | 05/16/2022
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Provider Practice Location Address
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Address Line | 1267 HIGHWAY 54 W STE 2200
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2110
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Country | US
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Telephone | 770-716-0051
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Fax |
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Provider Business Mailing Address
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Address Line | 110 FIELD ST APT D253
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City | NEWNAN
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State | GA
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Zip | 30263-1991
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Country | US
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Telephone | 435-609-3153
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10968
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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