Provider Demographics
NPI:1689131120
Name:DORRANCE, JAMES F IV (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:F
Last Name:DORRANCE
Suffix:IV
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 1:753 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1003
Mailing Address - Country:US
Mailing Address - Phone:608-835-2222
Mailing Address - Fax:608-835-1090
Practice Address - Street 1:753 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1003
Practice Address - Country:US
Practice Address - Phone:608-835-2222
Practice Address - Fax:608-835-1090
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI5205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1689131120Medicaid