Basic Information
| Provider Information | |||||||||
| NPI: | 1306817259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1869 | ||||||||
| Address2: | |||||||||
| City: | FLETCHER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287321869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286875698 | ||||||||
| FaxNumber: | 8286508076 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 VANCE HILL DR | ||||||||
| Address2: | |||||||||
| City: | MILLS RIVER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288917522 | ||||||||
| FaxNumber: | 8288917523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101222161 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2016-01589 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 42113 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1306817259 | 05 | VA | MEDICAID | P01081173 | 01 | VA | RR MEDICARE | OTHER | 3000080 | 05 | TN | MEDICAID |