Provider Demographics
NPI:1144834805
Name:JOHNSTON, LOGAN MICHAEL
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:MICHAEL
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE STE 1301
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2780
Mailing Address - Country:US
Mailing Address - Phone:503-228-0155
Mailing Address - Fax:503-226-8342
Practice Address - Street 1:511 SW 10TH AVE STE 1301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2780
Practice Address - Country:US
Practice Address - Phone:503-228-0155
Practice Address - Fax:503-226-8342
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical