Provider Demographics
NPI:1194724708
Name:LIPSCOMB, DALLAS W (PA-C)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:W
Last Name:LIPSCOMB
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:ELEPHANT BUTTE
Mailing Address - State:NM
Mailing Address - Zip Code:87935-0449
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:600 NM HWY 195
Practice Address - Street 2:STE A
Practice Address - City:ELEPHANT BUTTE
Practice Address - State:NM
Practice Address - Zip Code:87935-0449
Practice Address - Country:US
Practice Address - Phone:575-744-4872
Practice Address - Fax:575-548-7290
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
NMPA2013-0027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP46634Medicare UPIN
ILK05045Medicare PIN