Provider Demographics
NPI:1891865671
Name:PALMER, GREGORY SHAWN (BS, BHRS, CM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SHAWN
Last Name:PALMER
Suffix:
Gender:M
Credentials:BS, BHRS, CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29501 KICKAPOO RD
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-8320
Mailing Address - Country:US
Mailing Address - Phone:405-964-1617
Mailing Address - Fax:405-964-1759
Practice Address - Street 1:RR 1, BOX 35D
Practice Address - Street 2:
Practice Address - City:BOLEY
Practice Address - State:OK
Practice Address - Zip Code:74829
Practice Address - Country:US
Practice Address - Phone:918-667-3367
Practice Address - Fax:918-667-3387
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK#7173171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100685660AMedicaid
OK100685660BMedicaid
OK100685660DMedicaid