MEDICARE: MR. LOGAN THOMAS SMITH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA16831	TX

General Provider Information

NPI Number	:	1114615382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LOGAN THOMAS SMITH PA-C

Provider Business Mailing Address
First Line	:	8015 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-7018
Country	:	US
Telephone Number	:	817-453-4440
Fax Number	:

Provider Business Practice Location Address
First Line	:	8015 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-7018
Country	:	US
Telephone Number	:	817-453-4440
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2023
Last Update Date	:	04/26/2023

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