Provider Demographics
NPI:1033519194
Name:DAILEY, NICHOLAS DAKOTA (MS, LAT, ATC, PA-S)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:DAKOTA
Last Name:DAILEY
Suffix:
Gender:M
Credentials:MS, LAT, ATC, PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1322 MAPLEWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-8016
Mailing Address - Country:US
Mailing Address - Phone:304-647-5114
Mailing Address - Fax:
Practice Address - Street 1:1322 MAPLEWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:304-647-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0012302255A2300X
390200000X
WV869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program