Provider Demographics
NPI:1609843168
Name:DEROUSSE, JUSTINE M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:M
Last Name:DEROUSSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JUSTINE
Other - Middle Name:M
Other - Last Name:PIORKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 BAKER AVE
Mailing Address - Street 2:1222 HOMESTEADERS WAY
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2901
Mailing Address - Country:US
Mailing Address - Phone:406-862-2515
Mailing Address - Fax:406-862-4229
Practice Address - Street 1:350 HERITAGE WAY
Practice Address - Street 2:SUITE 1100
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3158
Practice Address - Country:US
Practice Address - Phone:406-752-8900
Practice Address - Fax:406-752-8905
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT451363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant