Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 06078 | LA |
NPI | 1003146226 |
---|---|
Provider Name | Dustin Allen Logue |
First Address | Baker, LA 70714-4911 |
Second Address | Baker, LA 70714-4911 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2010 |
Last Update Date | 12/10/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2110691 | (05) | LA |