Basic Information
| Provider Information | |||||||||
| NPI: | 1740931872 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALO | ||||||||
| FirstName: | KEATON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 47159 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554470159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635593779 | ||||||||
| FaxNumber: | 7634503986 | ||||||||
| Practice Location | |||||||||
| Address1: | 14700 28TH AVE N STE 20 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554474876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635593779 | ||||||||
| FaxNumber: | 7634503986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2022 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2215107 | MN | N | Nursing Service Providers | Registered Nurse | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 134383 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.