Provider Demographics
NPI:1861701567
Name:TALTY, PETER MICHAEL (OTR)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:MICHAEL
Last Name:TALTY
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-1024
Mailing Address - Country:US
Mailing Address - Phone:716-688-0022
Mailing Address - Fax:
Practice Address - Street 1:6000 BROCKTON DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-9273
Practice Address - Country:US
Practice Address - Phone:716-433-4718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000059172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker