Healthcare Provider Details

I. General information

NPI: 1568104701
Provider Name (Legal Business Name): JONATHAN CHRISTOPHER TYES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 GOODELL ST
BUFFALO NY
14203-1243
US

IV. Provider business mailing address

451 ELMWOOD AVE APT 506
BUFFALO NY
14222-2386
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-6106
  • Fax:
Mailing address:
  • Phone: 216-346-3341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: