Individual
LOGAN SLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1300 ANNE ST NW, BEMIDJI, MN 56601-5103
(218) 751-9746
Mailing address
PO BOX 5074, SIOUX FALLS, SD 57117-5074
(605) 328-9419
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
14888
MN
363A00000X
Physician Assistant
—
—
Other
Enumeration date
09/28/2022
Last updated
05/20/2024
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