Provider Demographics
NPI:1841273554
Name:BACK, DAWN R (PA)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:R
Last Name:BACK
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 1:117 CAMINO DE VIDA
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:575-472-4313
Practice Address - Street 1:117 CAMINO DE VIDA
Practice Address - Street 2:SUITE 300
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435
Practice Address - Country:US
Practice Address - Phone:575-472-4311
Practice Address - Fax:575-472-4313
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2016-0044363A00000X
AK2103363A00000X
COPA.0003777363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54452015Medicaid
524424YN9WMedicare UPIN