Provider Demographics
NPI:1679541932
Name:ROLLASON, DAVID H JR (PAC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:H
Last Name:ROLLASON
Suffix:JR
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:ISABEL
Mailing Address - State:SD
Mailing Address - Zip Code:57633-0097
Mailing Address - Country:US
Mailing Address - Phone:605-466-2120
Mailing Address - Fax:605-466-2190
Practice Address - Street 1:118 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ISABEL
Practice Address - State:SD
Practice Address - Zip Code:57633-0097
Practice Address - Country:US
Practice Address - Phone:605-466-2120
Practice Address - Fax:605-466-2190
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0106363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5350090Medicaid
SD02407OtherMED B
SD02407OtherMED B
R02516Medicare UPIN