Provider Demographics
NPI:1790439925
Name:MUTTEL, JOHN TYLER
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TYLER
Last Name:MUTTEL
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 1:200 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-2956
Mailing Address - Country:US
Mailing Address - Phone:973-356-8155
Mailing Address - Fax:
Practice Address - Street 1:200 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-2956
Practice Address - Country:US
Practice Address - Phone:570-422-3231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program