Provider Demographics
NPI:1285076661
Name:WINCKLER, DERRICK JOHN (PAC)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:JOHN
Last Name:WINCKLER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10099 RIDGEGATE PKWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-5531
Mailing Address - Country:US
Mailing Address - Phone:303-790-1800
Mailing Address - Fax:303-790-1809
Practice Address - Street 1:10099 RIDGEGATE PKWY
Practice Address - Street 2:SUITE 310
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5531
Practice Address - Country:US
Practice Address - Phone:303-790-1800
Practice Address - Fax:303-790-1809
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO0003752363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0003752OtherCO STATE LICENSE