Provider Demographics
NPI:1083945265
Name:PALMERSTON, MICHAEL R JR (BA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:PALMERSTON
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 ANUENUE ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-9734
Mailing Address - Country:US
Mailing Address - Phone:808-969-3488
Mailing Address - Fax:808-934-0071
Practice Address - Street 1:77 MOHOULI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4181
Practice Address - Country:US
Practice Address - Phone:808-961-5166
Practice Address - Fax:808-934-0071
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI302F00000X302F00000X
HI305R00000X302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization