Basic Information
| Provider Information | |||||||||
| NPI: | 1043967078 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SUSSMAN | ||||||||
| FirstName: | LOGAN | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2285 CORPORATE CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023602763 | ||||||||
| FaxNumber: | 9497832880 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 SEVEN HILLS DR STE 260 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890524373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029904800 | ||||||||
| FaxNumber: | 7029904808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2022 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2611 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.