Healthcare Provider Details

I. General information

NPI: 1942558036
Provider Name (Legal Business Name): NICHOLAS S DEPTULA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CAMPUS BLVD STE 300
WINCHESTER VA
22601-2872
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9200
US

V. Phone/Fax

Practice location:
  • Phone: 540-667-1244
  • Fax: 540-667-3086
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003988
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003988
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: