Provider Demographics
NPI:1154059061
Name:PALMEJAR, IAN RAY (FNP)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:RAY
Last Name:PALMEJAR
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9969 TESSON CREEK ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6298
Mailing Address - Country:US
Mailing Address - Phone:314-757-2338
Mailing Address - Fax:
Practice Address - Street 1:536 N TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1888
Practice Address - Country:US
Practice Address - Phone:314-449-1143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF05220729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily