Provider Demographics
NPI:1811941800
Name:GORTSEMA, JULIE JEANNE (PA-C)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:JEANNE
Last Name:GORTSEMA
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 CONRAN DR STE B
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1347
Practice Address - Country:US
Practice Address - Phone:616-267-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM56180PO2Medicare ID - Type UnspecifiedMEDICARE