Provider Demographics
NPI:1669736971
Name:PALMER, MELVIN BERNARD (PAC)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:BERNARD
Last Name:PALMER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 THIMBLE SHOALS BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4562
Mailing Address - Country:US
Mailing Address - Phone:757-873-1554
Mailing Address - Fax:757-873-3239
Practice Address - Street 1:730 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4562
Practice Address - Country:US
Practice Address - Phone:757-873-1554
Practice Address - Fax:757-873-3239
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003940363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1669736971OtherTRICARE
VA1669736971Medicaid
VA1669736971OtherHUMANA
VA0110003940OtherVA STATE LICENSE
VA556062OtherBLUE CROSS BLUE SHIELD MEDICARE SUPPLEMENT