Provider Demographics
NPI:1235383639
Name:PALMER, DINA G (PA)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:G
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 1:6640 INTECH BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-2012
Mailing Address - Country:US
Mailing Address - Phone:317-275-8308
Mailing Address - Fax:317-275-6066
Practice Address - Street 1:6640 INTECH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2012
Practice Address - Country:US
Practice Address - Phone:317-275-8308
Practice Address - Fax:317-275-6066
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002195363A00000X
IN10001245A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
D400001392OtherMEDICARE PTAN
INM400036141Medicare PIN
IN264910004Medicare PIN
D400001392OtherMEDICARE PTAN