Healthcare Provider Details

I. General information

NPI: 1033894910
Provider Name (Legal Business Name): TYLER WUNDRACH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15855 19 MILE RD
CLINTON TWP MI
48038-3504
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2320
  • Fax: 586-203-1050
Mailing address:
  • Phone: 800-999-5829
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011785
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601011785
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number5601011785
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: