Basic Information
| Provider Information | |||||||||
| NPI: | 1568128742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | MSN, AGACNP-BC, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 RED TIP LN | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281174350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043191540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 CHURCH ST N | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044033000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2021 | ||||||||
| LastUpdateDate: | 11/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | ROBE-AV5UG | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.