Healthcare Provider Details

I. General information

NPI: 1033519194
Provider Name (Legal Business Name): NICHOLAS DAKOTA DAILEY MS, LAT, ATC, PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 MAPLEWOOD AVE STE A
RONCEVERTE WV
24970-8016
US

IV. Provider business mailing address

1322 MAPLEWOOD AVE STE A
RONCEVERTE WV
24970-8016
US

V. Phone/Fax

Practice location:
  • Phone: 304-647-5114
  • Fax:
Mailing address:
  • Phone: 304-647-5114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number869
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001230
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: