Provider Demographics
NPI:1922606714
Name:ORCA-HANDYSIDE, JOHANNA-LEE
Entity Type:Individual
Prefix:
First Name:JOHANNA-LEE
Middle Name:
Last Name:ORCA-HANDYSIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 COTTAGE
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-2206
Mailing Address - Country:US
Mailing Address - Phone:269-689-9041
Mailing Address - Fax:
Practice Address - Street 1:104 S LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1947
Practice Address - Country:US
Practice Address - Phone:269-319-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010072TMP20363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant