Healthcare Provider Details

I. General information

NPI: 1659151413
Provider Name (Legal Business Name): TYLER JAMES SKONIECKI LAT, ATC, NREMT-B
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2023
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 STADIUM DR STALLINGS EVANS SPORTS MEDICINE CENTER
CHAPEL HILL NC
27515
US

IV. Provider business mailing address

57 DEER PATH DR
BERWICK PA
18603-5107
US

V. Phone/Fax

Practice location:
  • Phone: 919-962-2067
  • Fax:
Mailing address:
  • Phone: 570-855-4297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberP561644
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number1059757
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT5788
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: