Provider Demographics
NPI:1679859300
Name:ROZEMA, ASHLEY DANELLE (PA)
Entity type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:DANELLE
Last Name:ROZEMA
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 1:4100 EMBASSY DR SE STE 400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2416
Mailing Address - Country:US
Mailing Address - Phone:616-988-8220
Mailing Address - Fax:
Practice Address - Street 1:1840 WEALTHY ST SE DEPT
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-391-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019022166363A00000X
MI5601008140363A00000X
363AM0700X
NY014935-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220080922Medicaid