Provider Demographics
NPI:1063492114
Name:PALMER, MELISA L (PAC)
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:L
Last Name:PALMER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MELISA
Other - Middle Name:LYNN
Other - Last Name:SAYLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:523 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-3054
Mailing Address - Country:US
Mailing Address - Phone:218-829-2861
Mailing Address - Fax:
Practice Address - Street 1:523 N 3RD ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3054
Practice Address - Country:US
Practice Address - Phone:218-829-2861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS450Medicare ID - Type Unspecified
MDL603Medicare ID - Type Unspecified
S25127Medicare UPIN