Provider Demographics
NPI:1679908552
Name:HANNAH, ANGELA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:HANNAH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:MICHELLE
Other - Last Name:DERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:78 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421-5100
Practice Address - Country:US
Practice Address - Phone:231-854-6415
Practice Address - Fax:231-854-6975
Is Sole Proprietor?:No
Enumeration Date:2013-09-10
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant