Basic Information
| Provider Information | |||||||||
| NPI: | 1841273554 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACK | ||||||||
| FirstName: | DAWN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 CAMINO DE VIDA | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 CAMINO DE VIDA | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5754724311 | ||||||||
| FaxNumber: | 5754724313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2016-0044 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2103 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA.0003777 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 54452015 | 05 | NM | MEDICAID |