Provider Demographics
NPI:1679198220
Name:KILMER, DYLAN GARY
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:GARY
Last Name:KILMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 VESTAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13902-4400
Mailing Address - Country:US
Mailing Address - Phone:607-777-2000
Mailing Address - Fax:
Practice Address - Street 1:127 ROUTE 106
Practice Address - Street 2:
Practice Address - City:GREENFIELD TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18407-3526
Practice Address - Country:US
Practice Address - Phone:570-282-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PASP022372363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program