Healthcare Provider Details

I. General information

NPI: 1467176248
Provider Name (Legal Business Name): TYLER DAVID OWITZ NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2022
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 AVA MARIA DR
PHOENICIA NY
12464-5102
US

IV. Provider business mailing address

360 WASHINGTON AVE
KINGSTON NY
12401-3702
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-7140
  • Fax: 845-338-7141
Mailing address:
  • Phone: 845-338-7140
  • Fax: 845-338-7141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349957
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: