Individual
JAMES LYLE DERICKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1852 N MASTICK WAY, NOGALES, AZ 85621
(520) 281-1550
(520) 281-4487
Mailing address
825 N GRAND AVE STE 100, NOGALES, AZ 85621-1061
(520) 761-2133
(520) 281-2335
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
37067
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
266946
—
AZ
Enumeration date
07/17/2006
Last updated
11/28/2018
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