Provider Demographics
NPI:1346471802
Name:DERRICK, JAMES QUINCEY (PA)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:QUINCEY
Last Name:DERRICK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:TIERRA AMARILLA
Mailing Address - State:NM
Mailing Address - Zip Code:87575-0250
Mailing Address - Country:US
Mailing Address - Phone:575-588-7252
Mailing Address - Fax:575-588-9132
Practice Address - Street 1:CR 0324 HWY 84 N #14
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575
Practice Address - Country:US
Practice Address - Phone:575-588-7252
Practice Address - Fax:575-588-9132
Is Sole Proprietor?:No
Enumeration Date:2009-07-31
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant