Provider Demographics
NPI:1295324929
Name:OEGEMA, CORY DYLAN (PA)
Entity type:Individual
Prefix:MR
First Name:CORY
Middle Name:DYLAN
Last Name:OEGEMA
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W PARADISE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9795
Mailing Address - Country:US
Mailing Address - Phone:262-334-3451
Mailing Address - Fax:262-347-3044
Practice Address - Street 1:3901 STEWART AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-3948
Practice Address - Country:US
Practice Address - Phone:715-907-0900
Practice Address - Fax:715-803-6977
Is Sole Proprietor?:No
Enumeration Date:2021-01-17
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295324929Medicaid