Healthcare Provider Details

I. General information

NPI: 1588057319
Provider Name (Legal Business Name): JAMES RICHARD ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3676 PARKER BLVD
PUEBLO CO
81008-2212
US

IV. Provider business mailing address

P.O. BOX 9000 SOUTHERN COLORADO CLINIC
PUEBLO CO
82008-9000
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-1802
  • Fax:
Mailing address:
  • Phone: 719-553-1802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.0004455
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: