Provider Demographics
NPI:1114980158
Name:PALMER, CARRIE L (PA)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:L
Last Name:PALMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6934 W Q AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8942
Mailing Address - Country:US
Mailing Address - Phone:269-224-1659
Mailing Address - Fax:269-421-1067
Practice Address - Street 1:2855 CAPITAL AVE SW
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-6105
Practice Address - Country:US
Practice Address - Phone:269-979-6200
Practice Address - Fax:269-979-6201
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004608363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5131199OtherBCBS PIN
MIN88150002Medicare PIN
MI5131199OtherBCBS PIN