MEDICARE: MR. TYLER JAMES SKONIECKI LAT, ATC, NREMT-B

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	146N00000X	Basic Emergency Medical Technician	P561644	NC
2	146N00000X	Basic Emergency Medical Technician	1059757	PA
3	2255A2300X	Athletic Trainer	LAT5788	NC

General Provider Information

NPI Number	:	1659151413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TYLER JAMES SKONIECKI LAT, ATC, NREMT-B

Provider Business Mailing Address
First Line	:	57 DEER PATH DR
Second Line	:
City	:	BERWICK
State	:	PA
Zip	:	18603-5107
Country	:	US
Telephone Number	:	570-855-4297
Fax Number	:

Provider Business Practice Location Address
First Line	:	91 STADIUM DR
Second Line	:	STALLINGS EVANS SPORTS MEDICINE CENTER
City	:	CHAPEL HILL
State	:	NC
Zip	:	27515
Country	:	US
Telephone Number	:	919-962-2067
Fax Number	:

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

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	12/12/2025

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