MEDICARE: TYSON CORELL COTTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	BSO-16-00469	NY

General Provider Information

NPI Number	:	1255108049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYSON CORELL COTTON

Provider Business Mailing Address
First Line	:	320 GREECE RIDGE CENTER DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-2819
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 GREECE RIDGE CENTER DR
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14626-2819
Country	:	US
Telephone Number	:	585-733-9337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2023
Last Update Date	:	12/11/2023

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Directions to “ TYSON CORELL COTTON ” Practice Location

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