Provider Demographics
NPI:1003365396
Name:OUDSEMA, JUSTINE MELODIE (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:MELODIE
Last Name:OUDSEMA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:MELODIE
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:BOX 74
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8481
Mailing Address - Fax:269-341-7781
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:BOX 74
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8481
Practice Address - Fax:269-341-7781
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant