Individual
ALEXIS LOGAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
221 NE GLEN OAK AVE, PEORIA, IL 61636-0001
(309) 671-8297
Mailing address
221 NE GLEN OAK AVE, PEORIA, IL 61636-0001
(309) 671-8297
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085006727
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085006727
LICENSE
IL
Enumeration date
09/13/2018
Last updated
09/13/2018
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