MEDICARE: LOGAN NYE

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1629644083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOGAN NYE

Provider Business Mailing Address
First Line	:	WRIGHT STATE UNIVERSITY BOONSHOFT SCHOOL OF MEDICINE
Second Line	:	3460 COLONEL GLENN HWY
City	:	FAIRBORN
State	:	OH
Zip	:	45324
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2886 FOREST LAWN DR APT 3
Second Line	:
City	:	BEAVERCREEK
State	:	OH
Zip	:	45431-8865
Country	:	US
Telephone Number	:	440-563-8928
Fax Number	:

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

Provider Enumeration Date	:	05/27/2021
Last Update Date	:	05/27/2021

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Directions to “ LOGAN NYE ” Practice Location

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