Provider Demographics
NPI:1194751032
Name:PALOMBO, MICHAEL WAYNE (LAT, RVT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:PALOMBO
Suffix:
Gender:M
Credentials:LAT, RVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11421 COTTON LN
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2063
Mailing Address - Country:US
Mailing Address - Phone:225-317-1149
Mailing Address - Fax:
Practice Address - Street 1:11421 COTTON LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-2063
Practice Address - Country:US
Practice Address - Phone:225-317-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAJ00094174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist