Basic Information
| Provider Information | |||||||||
| NPI: | 1003884750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | MARCIA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 NW EXPRESSWAY | ||||||||
| Address2: | STE 610 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731127251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052869465 | ||||||||
| FaxNumber: | 4052869462 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057134740 | ||||||||
| FaxNumber: | 4057132974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA844 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 200011940A | 05 | OK | MEDICAID |