Basic Information
| Provider Information | |||||||||
| NPI: | 1295709939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALMISANO | ||||||||
| FirstName: | DOMINICK | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7912 E 31ST CT | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741451315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183924456 | ||||||||
| FaxNumber: | 9183924465 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 N MUSKOGEE PL | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740173058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183924456 | ||||||||
| FaxNumber: | 9183924465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0049310 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 100783690A | 05 | OK | MEDICAID | 1285810051 | 01 | OK | MEDICARE GROUP PIN | OTHER |