Provider Demographics
NPI:1215929419
Name:PALMER, GLEN (PHD)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:
Last Name:PALMER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-4453
Mailing Address - Country:US
Mailing Address - Phone:402-463-7711
Mailing Address - Fax:
Practice Address - Street 1:715 N KANSAS AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-4453
Practice Address - Country:US
Practice Address - Phone:402-463-7711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE505174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE08192OtherBLUE CROSS BLUE SHIELD NE
NE08192OtherBLUE CROSS BLUE SHIELD NE
NEP10795Medicare UPIN