Healthcare Provider Details

I. General information

NPI: 1649300864
Provider Name (Legal Business Name): NICHOLAS AARON KILPATRICK PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1907
US

IV. Provider business mailing address

1201 GRAMPIAN BLVD
WILLIAMSPORT PA
17701-1900
US

V. Phone/Fax

Practice location:
  • Phone: 570-320-7444
  • Fax: 570-320-7445
Mailing address:
  • Phone: 570-326-8723
  • Fax: 570-326-8922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003388
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061942
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: