Healthcare Provider Details

I. General information

NPI: 1295324929
Provider Name (Legal Business Name): CORY DYLAN OEGEMA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 STEWART AVE
WAUSAU WI
54401-3948
US

IV. Provider business mailing address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

V. Phone/Fax

Practice location:
  • Phone: 715-907-0900
  • Fax: 715-803-6977
Mailing address:
  • Phone: 262-334-3451
  • Fax: 262-347-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5418
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: