Basic Information
| Provider Information | |||||||||
| NPI: | 1548824790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALMER | ||||||||
| FirstName: | HASKELL | ||||||||
| MiddleName: | TRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168 | ||||||||
| Address2: | |||||||||
| City: | ELGIN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735380168 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 W GORE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803558620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2019 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 81480 | NE | N | Nursing Service Providers | Registered Nurse | 367500000X | M113074 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.