Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 30.026132 | OH |
Y | 213EG0000X | General Practice | 30.026132 | OH |
NPI | 1003439530 |
---|---|
Provider Name | Logan Williams |
First Address | Mentor, OH 44060-2448 |
Second Address | Mentor, OH 44060-4924 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2020 |
Last Update Date | 17/06/2020 |