MEDICARE: LORALYN H LOGAN PA

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	363AM0700X	Medical Physician Assistant	PA04753	TX
2	363A00000X	Physician Assistant	PA04753	TX

General Provider Information

NPI Number	:	1174550370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORALYN H LOGAN PA

Provider Business Mailing Address
First Line	:	710 FM 1960 RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-3402
Country	:	US
Telephone Number	:	281-440-2543
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 FM 1960 RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77090-3402
Country	:	US
Telephone Number	:	281-440-2543
Fax Number	:

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

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	10/03/2012

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Directions to “ LORALYN H LOGAN PA” Practice Location

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