Provider Demographics
NPI:1659332435
Name:PALMER, SALLY A (NP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:A
Last Name:PALMER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6600
Mailing Address - Country:US
Mailing Address - Phone:315-637-7878
Mailing Address - Fax:315-329-7825
Practice Address - Street 1:4101 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6610
Practice Address - Country:US
Practice Address - Phone:315-637-7878
Practice Address - Fax:315-329-7825
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300475363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8166Medicare ID - Type Unspecified
NYP00173Medicare UPIN