Provider Demographics
NPI:1326145236
Name:BOAG, JULIE LYNN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:LYNN
Last Name:BOAG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14555 LEVAN RD
Mailing Address - Street 2:STE 410
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-5085
Mailing Address - Country:US
Mailing Address - Phone:734-462-9499
Mailing Address - Fax:734-462-4124
Practice Address - Street 1:14555 LEVAN RD
Practice Address - Street 2:STE 410
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-5085
Practice Address - Country:US
Practice Address - Phone:734-462-9499
Practice Address - Fax:734-462-4124
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S69952Medicare UPIN
MIOP12350004Medicare ID - Type Unspecified