Basic Information
| Provider Information | |||||||||
| NPI: | 1548518798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REGDOS | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MASKULINSKI | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | BOX 8000 DEPT 314 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162130772 | ||||||||
| FaxNumber: | 7163245004 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 DOUGLAS LN | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140522124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167149860 | ||||||||
| FaxNumber: | 7167149864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2012 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 035477 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 06012399 | 05 | NY | MEDICAID |