=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841273554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN R BACK PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2005
-----------------------------------------------------
Last Update Date | 02/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 CAMINO DE VIDA SUITE 300
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-472-4311
-----------------------------------------------------
Fax | 575-472-4313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 CAMINO DE VIDA SUITE 300
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-472-4311
-----------------------------------------------------
Fax | 575-472-4313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA2016-0044
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2103
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA.0003777
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------