Basic Information
| Provider Information | |||||||||
| NPI: | 1376725697 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LOGAN | ||||||||
| FirstName: | GINA | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 WASHINGTON ST | ||||||||
| Address2: | EIGHT TOWER BRIDGE, SUITE 1400 | ||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668253227 | ||||||||
| FaxNumber: | 4844502617 | ||||||||
| Practice Location | |||||||||
| Address1: | 7440 FM 1960 RD E | ||||||||
| Address2: | |||||||||
| City: | HUMBLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773463129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663253227 | ||||||||
| FaxNumber: | 4844502617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 11/28/2007 | ||||||||
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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 | 363A00000X | PA02030 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA02030 | 01 | TX | LICENSE | OTHER |