MEDICARE: NICHOLAS S DEPTULA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	0110003988	VA
2	363A00000X	Physician Assistant	0110003988	VA

General Provider Information

NPI Number	:	1942558036
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS S DEPTULA PA-C

Provider Business Mailing Address
First Line	:	5000 COX RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-9200
Country	:	US
Telephone Number	:	804-968-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	190 CAMPUS BLVD STE 300
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22601-2872
Country	:	US
Telephone Number	:	540-667-1244
Fax Number	:	540-667-3086

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2012
Last Update Date	:	04/27/2026

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