Provider Demographics
NPI:1710975586
Name:DERRISAW, JAMES ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALAN
Last Name:DERRISAW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1236 E ELIZABETH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4000
Mailing Address - Country:US
Mailing Address - Phone:970-224-2985
Mailing Address - Fax:970-472-9381
Practice Address - Street 1:1236 E ELIZABETH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4000
Practice Address - Country:US
Practice Address - Phone:970-224-2985
Practice Address - Fax:970-472-9381
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO39525208VP0014X
NE26018207L00000X
WY6553A207L00000X
CODR.0039525207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04051262Medicaid
WY119537900Medicaid
COH38662Medicare UPIN
CO04051262Medicaid
WY119537900Medicaid
COP00027067Medicare PIN