Provider Demographics
NPI:1023362639
Name:PALMER, TIMOTHY ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:PALMER
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 1:4333 W ST JOE HWY
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-4100
Mailing Address - Country:US
Mailing Address - Phone:517-321-1525
Mailing Address - Fax:517-321-7059
Practice Address - Street 1:4333 W ST JOE HWY
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4100
Practice Address - Country:US
Practice Address - Phone:517-321-1525
Practice Address - Fax:517-321-7059
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006540363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601006540Medicare UPIN