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General NPI Number Information
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NPI Number | 1578180006
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Entity Type | Individual
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Provider Name | LOGAN MOCK PA
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Gender | Male
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Dates
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Enumeration Date | 06/30/2020
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 215 BRIGHTWATER DR
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City | LILLINGTON
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State | NC
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Zip | 27546-5156
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Country | US
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Telephone | 704-765-2578
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Fax |
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Provider Business Mailing Address
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Address Line | 200 QUEENS RD STE 400
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City | CHARLOTTE
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State | NC
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Zip | 28204-3264
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Country | US
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Telephone | 704-765-2578
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Fax | 707-333-3397
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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 |
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License Number State |
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