Provider Demographics
NPI:1265049860
Name:ROLLASON, MIRIAM CHRISTINE (PA)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:CHRISTINE
Last Name:ROLLASON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 E GOLF PL
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9313
Mailing Address - Country:US
Mailing Address - Phone:605-850-3924
Mailing Address - Fax:
Practice Address - Street 1:810 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5728
Practice Address - Country:US
Practice Address - Phone:970-764-1790
Practice Address - Fax:970-375-7927
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-28
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
COPA.0006450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant