Healthcare Provider Details

I. General information

NPI: 1407975451
Provider Name (Legal Business Name): JOHN TIFFANY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 FAY RD
SYRACUSE NY
13219-3009
US

IV. Provider business mailing address

304 S LOWELL AVE
SYRACUSE NY
13204-2633
US

V. Phone/Fax

Practice location:
  • Phone: 315-488-2831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number493860
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: