Provider Demographics
NPI:1669424396
Name:PURDY-KANAS, LISA EVELYN (DC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:EVELYN
Last Name:PURDY-KANAS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47101 HAYES RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-1213
Mailing Address - Country:US
Mailing Address - Phone:586-532-9774
Mailing Address - Fax:586-532-9767
Practice Address - Street 1:47101 HAYES
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-1213
Practice Address - Country:US
Practice Address - Phone:586-532-9774
Practice Address - Fax:586-532-9767
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005277111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102491OtherGREAT LAKES HEALTH PLAN
MI3357077Medicaid
MI950E05212OtherBCBSM
MICH500091OtherMCARE
MIU13967Medicare UPIN
MI950E05212OtherBCBSM