Basic Information
| Provider Information | |||||||||
| NPI: | 1548534175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT | ||||||||
| Address2: | PO BOX 7291 | ||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042437291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778560 | ||||||||
| FaxNumber: | 2077778800 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079071430 | ||||||||
| FaxNumber: | 2079073508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/29/2012 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 26NJ00367900 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RNA163052 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.