Provider Demographics
NPI:1588057319
Name:ANDERSON, JAMES RICHARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RICHARD
Last Name:ANDERSON
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:P.O. BOX 9000
Mailing Address - Street 2:SOUTHERN COLORADO CLINIC
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:82008-9000
Mailing Address - Country:US
Mailing Address - Phone:719-553-1802
Mailing Address - Fax:
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2212
Practice Address - Country:US
Practice Address - Phone:719-553-1802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-18
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004455363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical