Provider Demographics
NPI:1811656218
Name:PETERSON, TYLER (DPT, PT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ANTHONY LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-1064
Mailing Address - Country:US
Mailing Address - Phone:315-939-0317
Mailing Address - Fax:
Practice Address - Street 1:205 EAST AVE
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2156
Practice Address - Country:US
Practice Address - Phone:315-939-0317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0482322251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics