Provider Demographics
NPI:1457459448
Name:DERRICK, JAMES L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:L
Last Name:DERRICK
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 1:2000 HEALTH PARK DR FL HP2
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4692
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3530
Practice Address - Fax:540-776-2036
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008289363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMD0124292OtherDEA
NC100929OtherNC LICENSE
NCP63906Medicare UPIN
NCMD0124292OtherDEA
NCMD0124292OtherDEA