Provider Demographics
NPI:1275664047
Name:MALSOM, DAWN M (PAC)
Entity Type:Individual
Prefix:MS
First Name:DAWN
Middle Name:M
Last Name:MALSOM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 W 29TH STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-5474
Mailing Address - Country:US
Mailing Address - Phone:970-652-2433
Mailing Address - Fax:970-652-2252
Practice Address - Street 1:6767 WEST 29TH STREET
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-8063
Practice Address - Country:US
Practice Address - Phone:970-652-2433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07175043Medicaid
CO07175043Medicaid