Provider Demographics
NPI:1033894910
Name:WUNDRACH, TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WUNDRACH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48423 MONTELEPRE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4153
Mailing Address - Country:US
Mailing Address - Phone:586-553-2102
Mailing Address - Fax:
Practice Address - Street 1:1 HURLEY PLZ # 7B
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9355
Practice Address - Fax:810-262-6341
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI56010117852086S0127X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery