Provider Demographics
NPI:1134550049
Name:WILLER, NICKOLAS (PA-C)
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:
Last Name:WILLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EVANS ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:1650 COCHRANE CIR B7500
Mailing Address - City:FT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:719-524-2709
Practice Address - Street 1:EVANS ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:1650 COCHRANE CIR B7500
Practice Address - City:FT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:254-287-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant