Provider Demographics
NPI:1164211496
Name:BARNEWOLT, LOGAN RILEY
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:RILEY
Last Name:BARNEWOLT
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 1:544 TRINIDAD POINT CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1063
Mailing Address - Country:US
Mailing Address - Phone:702-686-5791
Mailing Address - Fax:
Practice Address - Street 1:1475 RAIDERS WAY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4604
Practice Address - Country:US
Practice Address - Phone:702-686-5791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer