Basic Information
Provider Information
NPI: 1003146226
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LOGUE
FirstName: DUSTIN
MiddleName: ALLEN
NamePrefix:  
NameSuffix:  
Credential: ANP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 4176
Address2:  
City: HOUMA
State: LA
PostalCode: 703614176
CountryCode: US
TelephoneNumber: 9858725864
FaxNumber: 9858720317
Practice Location
Address1: 6550 MAIN ST
Address2:  
City: ZACHARY
State: LA
PostalCode: 707914072
CountryCode: US
TelephoneNumber: 2256541559
FaxNumber: 2256546212
Other Information
ProviderEnumerationDate: 01/11/2010
LastUpdateDate: 07/06/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000XRN110597-AP06078LAY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 

ID Information
IDTypeStateIssuerDescription
211069105LA MEDICAID


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