Basic Information
| Provider Information | |||||||||
| NPI: | 1265049860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROLLASON | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 E GOLF PL | ||||||||
| Address2: | |||||||||
| City: | PAGOSA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 811479313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6058503924 | ||||||||
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| Practice Location | |||||||||
| Address1: | 810 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813015728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707641790 | ||||||||
| FaxNumber: | 9703757927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2020 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA.0006450 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.