=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316814791
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER NICHOLAS MACZKO
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2025
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2305 PLEASANT AVE APT B
-----------------------------------------------------
City | WELLSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26070-1383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-834-8092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2305 PLEASANT AVE APT B
-----------------------------------------------------
City | WELLSBURG
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26070-1383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-834-8092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------