Provider Demographics
NPI:1578048138
Name:ATTISHA, JORDAN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:ATTISHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:MARIE
Other - Last Name:ZURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:27275 HAGGERTY RD STE 500
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3635
Mailing Address - Country:US
Mailing Address - Phone:248-741-6909
Mailing Address - Fax:248-513-4301
Practice Address - Street 1:17800 NEWBURGH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2700
Practice Address - Country:US
Practice Address - Phone:734-464-9540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-30
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008850OtherPHYSICIAN ASSISTANT
5315095708OtherCONTROLLED SUBSTANCE- 2