Provider Demographics
NPI: | 1477674356 |
---|---|
Name: | PALMER, SHANIQUE R (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | SHANIQUE |
Middle Name: | R |
Last Name: | PALMER |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | P O BOX 388 |
Mailing Address - Street 2: | |
Mailing Address - City: | FISHERSVILLE |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 22939-0388 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 540-932-4629 |
Mailing Address - Fax: | 540-932-4616 |
Practice Address - Street 1: | 78 MEDICAL CENTER DRIVE |
Practice Address - Street 2: | |
Practice Address - City: | FISHERSVILLE |
Practice Address - State: | VA |
Practice Address - Zip Code: | 22939-2332 |
Practice Address - Country: | US |
Practice Address - Phone: | 540-221-7150 |
Practice Address - Fax: | 540-332-5962 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-04-02 |
Last Update Date: | 2021-06-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
390200000X | ||
VA | 0101251327 | 207RH0003X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | GC1100 | Medicare PIN | |
MN | 110012038 | Medicare PIN |