Provider Demographics
NPI:1538178058
Name:KORHONEN, DERYCK A (PA-C)
Entity type:Individual
Prefix:
First Name:DERYCK
Middle Name:A
Last Name:KORHONEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N15995 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POWERS
Mailing Address - State:MI
Mailing Address - Zip Code:49874-9608
Mailing Address - Country:US
Mailing Address - Phone:906-497-4360
Mailing Address - Fax:906-497-4362
Practice Address - Street 1:N15995 MAIN ST
Practice Address - Street 2:
Practice Address - City:POWERS
Practice Address - State:MI
Practice Address - Zip Code:49874-9608
Practice Address - Country:US
Practice Address - Phone:906-497-4360
Practice Address - Fax:906-497-4362
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970016972OtherRR MEDICARE GROUP#CC2139
MI970016972OtherRR MEDICARE GROUP#CC2139
MIP22213Medicare UPIN