Basic Information
| Provider Information | |||||||||
| NPI: | 1003146226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOGUE | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | ANP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12902 PLANK RD | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707144911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253697006 | ||||||||
| FaxNumber: | 2257742827 | ||||||||
| Practice Location | |||||||||
| Address1: | 12902 PLANK RD | ||||||||
| Address2: | |||||||||
| City: | BAKER | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707144911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2253697006 | ||||||||
| FaxNumber: | 2257742827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2010 | ||||||||
| LastUpdateDate: | 10/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 06078 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 2110691 | 05 | LA | MEDICAID |