Provider Demographics
NPI:1467176248
Name:OWITZ, TYLER DAVID (NP)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:DAVID
Last Name:OWITZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3702
Mailing Address - Country:US
Mailing Address - Phone:845-338-7140
Mailing Address - Fax:845-338-7141
Practice Address - Street 1:9 AVA MARIA DR
Practice Address - Street 2:
Practice Address - City:PHOENICIA
Practice Address - State:NY
Practice Address - Zip Code:12464-5102
Practice Address - Country:US
Practice Address - Phone:845-338-7140
Practice Address - Fax:845-338-7141
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY349957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily