Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 2018029949 | MO |
Y | 213ES0000X | Sports Medicine | 2018029949 | MO |
NPI | 1073168399 |
---|---|
Provider Name | Logan Prescott |
First Address | Springfield, MO 65802-9494 |
Second Address | Springfield, MO 65807-7310 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2019 |
Last Update Date | 04/08/2019 |