Healthcare Provider Details

I. General information

NPI: 1285380196
Provider Name (Legal Business Name): TYLER J SHOTTO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ROUTE 715
BRODHEADSVILLE PA
18322-7101
US

IV. Provider business mailing address

100 DREAM DR APT C34
WIND GAP PA
18091-7700
US

V. Phone/Fax

Practice location:
  • Phone: 272-212-0430
  • Fax:
Mailing address:
  • Phone: 570-903-9994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberPT030276
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: