Basic Information
| Provider Information | |||||||||
| NPI: | 1386214807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTIS | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1412 SWEET HOME RD STE 3-5 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165891411 | ||||||||
| FaxNumber: | 7162763051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1412 SWEET HOME RD STE 3-5 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165891411 | ||||||||
| FaxNumber: | 7162763051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2021 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.