Provider Demographics
NPI:1033588363
Name:REERSLEV, MOUSHUMI-DEVYANI CAMILLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MOUSHUMI-DEVYANI
Middle Name:CAMILLE
Last Name:REERSLEV
Suffix:
Gender:F
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 1:355 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97448-1313
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 HAYDEN BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1347
Practice Address - Country:US
Practice Address - Phone:541-868-9430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA172342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant