Provider Demographics
NPI:1790757730
Name:BOTTAR, TIFFANY (PT)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:BOTTAR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4305 WEST SENECA ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-6638
Mailing Address - Country:US
Mailing Address - Phone:315-682-0325
Mailing Address - Fax:315-682-0295
Practice Address - Street 1:240 WEST SENECA STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104
Practice Address - Country:US
Practice Address - Phone:315-682-0325
Practice Address - Fax:315-682-0295
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0254631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ4000Medicare PIN