Provider Demographics
NPI:1801900121
Name:MITCHELSON, JUDY J (PA)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:J
Last Name:MITCHELSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-8474
Mailing Address - Country:US
Mailing Address - Phone:269-695-5540
Mailing Address - Fax:
Practice Address - Street 1:10310 MILLER DR
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:MI
Practice Address - Zip Code:49053
Practice Address - Country:US
Practice Address - Phone:269-286-7150
Practice Address - Fax:269-286-7151
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002830363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP02235Medicare UPIN
MIOM97270Medicare ID - Type Unspecified