Basic Information
Provider Information | |||||||||
NPI: | 1902335235 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TYTKA | ||||||||
FirstName: | BRANDON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BOX 8000 | ||||||||
Address2: | DEPARTMENT 314 | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142670002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7162130772 | ||||||||
FaxNumber: | 7163245004 | ||||||||
Practice Location | |||||||||
Address1: | 5959 BIG TREE RD STE 108 | ||||||||
Address2: |   | ||||||||
City: | ORCHARD PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 141272291 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7162043200 | ||||||||
FaxNumber: | 7162044337 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2017 | ||||||||
LastUpdateDate: | 05/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 042444 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 05710334 | 05 | NY |   | MEDICAID |