Provider Demographics
NPI:1619459120
Name:BITTNER, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BITTNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:692 ADMIRALTY WAY
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-3904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:145-808-8888
Practice Address - Street 1:1550 EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2104
Practice Address - Country:US
Practice Address - Phone:585-922-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL039635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist