Provider Demographics
NPI:1992192587
Name:PALOMINO, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:PALOMINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 DOUG WHITE DR STE 510
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4183
Mailing Address - Country:US
Mailing Address - Phone:843-497-7772
Mailing Address - Fax:843-848-7530
Practice Address - Street 1:920 DOUG WHITE DR STE 510
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4183
Practice Address - Country:US
Practice Address - Phone:843-497-7772
Practice Address - Fax:843-848-7530
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC85375208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program