Basic Information
| Provider Information | |||||||||
| NPI: | 1558602888 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HYDE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBERTS | ||||||||
| OtherFirstName: | LISA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5329 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486030329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163646700 | ||||||||
| FaxNumber: | 9894014245 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 JEFFERSON AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166856200 | ||||||||
| FaxNumber: | 6166858993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2013 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601006602 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.