Provider Demographics
NPI:1285367722
Name:LANCELLOTTI, CODY TYLER (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:TYLER
Last Name:LANCELLOTTI
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2178 HAIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW FREEDOM
Mailing Address - State:PA
Mailing Address - Zip Code:17349-9268
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 GREENSPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:STEVENSON
Practice Address - State:MD
Practice Address - Zip Code:21153-0641
Practice Address - Country:US
Practice Address - Phone:717-825-6756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA01097207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine