Provider Demographics
NPI:1285380196
Name:SHOTTO, TYLER J (DPT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:SHOTTO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DREAM DR APT C34
Mailing Address - Street 2:
Mailing Address - City:WIND GAP
Mailing Address - State:PA
Mailing Address - Zip Code:18091-7700
Mailing Address - Country:US
Mailing Address - Phone:570-903-9994
Mailing Address - Fax:
Practice Address - Street 1:111 ROUTE 715
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-7101
Practice Address - Country:US
Practice Address - Phone:272-212-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0302762081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine