Provider Demographics
NPI:1558602888
Name:HYDE, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HYDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7400 KIRKWOOD TRL SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9187
Mailing Address - Country:US
Mailing Address - Phone:616-813-6634
Mailing Address - Fax:989-401-4245
Practice Address - Street 1:655 KENMOOR AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8604
Practice Address - Country:US
Practice Address - Phone:616-920-0825
Practice Address - Fax:616-920-0830
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601006602363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant