Basic Information
| Provider Information | |||||||||
| NPI: | 1285732859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | JOY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6622 N 91ST AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853052569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027596883 | ||||||||
| FaxNumber: | 6022243358 | ||||||||
| Practice Location | |||||||||
| Address1: | 4475 S L-19 FRONTAGE ROAD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205854590 | ||||||||
| FaxNumber: | 5203987540 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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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 | 207RN0300X | 10447 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 241711 | 05 | AZ | MEDICAID |