Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | DC007097L | PA |
Y | 111NS0005X | Chiropractic Sports Physician | 4038 | PA |
NPI | 1003929308 |
---|---|
Provider Name | Dr. Timothy B Vyrostek |
First Address | Conneaut Lake, PA 16316 |
Second Address | Conneaut Lake, PA 16316 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2006 |
Last Update Date | 08/01/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0016549110004 | (05) | PA |
205055 | UPMC (01) | PA |
961159 | BCBS (01) | PA |
U67248 | (02) |