Provider Demographics
NPI:1275512402
Name:PALMER, MARK WESLEY (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WESLEY
Last Name:PALMER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1212
Mailing Address - Country:US
Mailing Address - Phone:405-609-3658
Mailing Address - Fax:800-506-3795
Practice Address - Street 1:1115 GARTH BROOKS BLVD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4106
Practice Address - Country:US
Practice Address - Phone:405-354-6698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT 2236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK249506602Medicare UPIN