Provider Demographics
NPI:1043288954
Name:WINGER-TALLENT, JULIE (PA)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:WINGER-TALLENT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:KLAFT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1863
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003806363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP72089Medicare UPIN
MI0N33470056Medicare ID - Type Unspecified