Healthcare Provider Details

I. General information

NPI: 1346273869
Provider Name (Legal Business Name): JAMES DETRICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11020 HULL STREET RD
MIDLOTHIAN VA
23112-3200
US

IV. Provider business mailing address

PO BOX 409540
ATLANTA GA
30384-9540
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-6310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPENDING
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002348
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: