Basic Information
Provider Information | |||||||||
NPI: | 1568471290 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOGAN | ||||||||
FirstName: | BETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8717 W 110TH ST | ||||||||
Address2: | SUITE 600 | ||||||||
City: | OVERLAND PARK | ||||||||
State: | KS | ||||||||
PostalCode: | 662102144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9134282900 | ||||||||
FaxNumber: | 9134282951 | ||||||||
Practice Location | |||||||||
Address1: | 19550 E 39TH ST S | ||||||||
Address2: | SUITE 100 | ||||||||
City: | INDEPENDENCE | ||||||||
State: | MO | ||||||||
PostalCode: | 640572358 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9134282910 | ||||||||
FaxNumber: | 9134282951 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 10/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 144253 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.