Healthcare Provider Details

I. General information

NPI: 1841273554
Provider Name (Legal Business Name): DAWN R BACK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 CAMINO DE VIDA SUITE 300
SANTA ROSA NM
88435
US

IV. Provider business mailing address

117 CAMINO DE VIDA SUITE 300
SANTA ROSA NM
88435
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-4311
  • Fax: 575-472-4313
Mailing address:
  • Phone: 575-472-4311
  • Fax: 575-472-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0044
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2103
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003777
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: