Provider Demographics
NPI:1447355474
Name:DERUM, JAMES P (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:P
Last Name:DERUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:67871 VALLEY VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-2351
Mailing Address - Country:US
Mailing Address - Phone:760-668-0768
Mailing Address - Fax:
Practice Address - Street 1:1990 N CALIFORNIA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-7249
Practice Address - Country:US
Practice Address - Phone:925-225-5837
Practice Address - Fax:925-225-5838
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA16110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P70866Medicare UPIN
0PA161101Medicare PIN