Provider Demographics
NPI:1659305480
Name:GAMM, JODIE L (PA)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:L
Last Name:GAMM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:L
Other - Last Name:KROENING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-727-4789
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-672-3916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP17640018Medicare PIN
P18720Medicare UPIN
MIG06043055Medicare PIN