Basic Information
| Provider Information | |||||||||
| NPI: | 1770964157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 W MAIN ST STE 340 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453733384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379807460 | ||||||||
| FaxNumber: | 9379807464 | ||||||||
| Practice Location | |||||||||
| Address1: | 1258 BELLEFONTAINE ST STE A | ||||||||
| Address2: | |||||||||
| City: | WAPAKONETA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197391980 | ||||||||
| FaxNumber: | 4197391982 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.17702-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN.CNP.17702 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0139583 | 05 | OH | MEDICAID |