MEDICARE: DAWN R BACK PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA2016-0044	NM
2	363A00000X	Physician Assistant	2103	AK
3	363A00000X	Physician Assistant	PA.0003777	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841273554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN R BACK PA

Provider Business Mailing Address
First Line	:	117 CAMINO DE VIDA
Second Line	:	SUITE 300
City	:	SANTA ROSA
State	:	NM
Zip	:	88435
Country	:	US
Telephone Number	:	575-472-4311
Fax Number	:	575-472-4313

Provider Business Practice Location Address
First Line	:	117 CAMINO DE VIDA
Second Line	:	SUITE 300
City	:	SANTA ROSA
State	:	NM
Zip	:	88435
Country	:	US
Telephone Number	:	575-472-4311
Fax Number	:	575-472-4313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	02/08/2017

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Directions to “ DAWN R BACK PA” Practice Location

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