MEDICARE: JULIE JEANNE GORTSEMA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5601003152	MI

General Provider Information

NPI Number	:	1811941800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE JEANNE GORTSEMA PA-C

Provider Business Mailing Address
First Line	:	100 MICHIGAN ST NE # MC845
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-2560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 CONRAN DR STE B
Second Line	:
City	:	COOPERSVILLE
State	:	MI
Zip	:	49404-1347
Country	:	US
Telephone Number	:	616-267-7860
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	04/14/2025

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