Provider Demographics
NPI:1154760650
Name:LIPA, JULIE WALTERS (PA-C)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:WALTERS
Last Name:LIPA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:CAMPBELL
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:26025 LAHSER RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2606
Mailing Address - Country:US
Mailing Address - Phone:248-703-9408
Mailing Address - Fax:
Practice Address - Street 1:26025 LAHSER RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2606
Practice Address - Country:US
Practice Address - Phone:248-703-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1154760650Medicaid