Provider Demographics
NPI:1619030970
Name:PALMBAUM, GLENN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:
Last Name:PALMBAUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-3936
Mailing Address - Country:US
Mailing Address - Phone:530-301-5780
Mailing Address - Fax:530-743-7971
Practice Address - Street 1:724 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5646
Practice Address - Country:US
Practice Address - Phone:530-743-7413
Practice Address - Fax:530-743-7971
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15585207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant