Provider Demographics
NPI:1689663783
Name:DABOLL, DAVID (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DABOLL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101-2302
Mailing Address - Country:US
Mailing Address - Phone:719-589-3658
Mailing Address - Fax:719-589-0997
Practice Address - Street 1:1710 1ST ST
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101-2302
Practice Address - Country:US
Practice Address - Phone:719-589-3658
Practice Address - Fax:719-589-0997
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840706945079OtherROCKY MOUNTAIN HEALTH PLA
970028613OtherTRAVELERS MEDICARE
P60781Medicare UPIN
468018Medicare ID - Type Unspecified