Healthcare Provider Details

I. General information

NPI: 1386982148
Provider Name (Legal Business Name): LISA DIANE THURMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2013
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 MERCY DR
MUSKEGON MI
49444-1837
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-7030
  • Fax: 231-739-8932
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006610
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: