Provider Demographics
NPI:1235790353
Name:LOGSDON, AMANDA (PA-C)
Entity type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:
Last Name:LOGSDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5838 METRO WAY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9619
Mailing Address - Country:US
Mailing Address - Phone:616-249-5300
Mailing Address - Fax:616-249-5315
Practice Address - Street 1:5838 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9619
Practice Address - Country:US
Practice Address - Phone:616-249-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-28
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009486363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant