Basic Information
| Provider Information | |||||||||
| NPI: | 1013550425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINKEVITCH | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUERKSEN | ||||||||
| OtherFirstName: | LOGAN | ||||||||
| OtherMiddleName: | RENAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671148778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162836103 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 126 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HALSTEAD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670561708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168353700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2019 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 53-79018-072 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201290060A | 05 | KS | MEDICAID | F09191416 | 01 | AMERICAN ACADEMY OF NURSE PRACTITIONERS CERTIFICATION | OTHER |