Basic Information
| Provider Information | |||||||||
| NPI: | 1073562807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3622 BELMONT AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | YOUNGSTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445051450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307599350 | ||||||||
| FaxNumber: | 3307599387 | ||||||||
| Practice Location | |||||||||
| Address1: | 3893 E MARKET ST | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444844706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308561272 | ||||||||
| FaxNumber: | 3308562960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 03/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-135649 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | COA.00492-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0847963 | 05 | OH | MEDICAID | 11894927 | 01 | OH | CAQH | OTHER |