Healthcare Provider Details

I. General information

NPI: 1427500537
Provider Name (Legal Business Name): NICHOLAS R DAWSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST 3RD FL AREA 1
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

PO BOX 26666 PHS PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-0340
  • Fax: 505-367-0346
Mailing address:
  • Phone: 956-566-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0070
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: