Provider Demographics
NPI:1902335235
Name:TYTKA, BRANDON (PT DPT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:TYTKA
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 8000
Mailing Address - Street 2:DEPARTMENT 314
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:716-213-0772
Mailing Address - Fax:716-324-5004
Practice Address - Street 1:5959 BIG TREE RD STE 108
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2291
Practice Address - Country:US
Practice Address - Phone:716-204-3200
Practice Address - Fax:716-204-4337
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042444225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05710334Medicaid