Provider Demographics
NPI:1871315853
Name:LARGE, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:LARGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CAREW ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2485
Mailing Address - Country:US
Mailing Address - Phone:413-794-9816
Mailing Address - Fax:
Practice Address - Street 1:300 CAREW ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2485
Practice Address - Country:US
Practice Address - Phone:413-794-9816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program