Provider Demographics
NPI:1285774240
Name:PALMER, MARK A (CRNA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:PALMER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 SUNSET HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9648
Mailing Address - Country:US
Mailing Address - Phone:518-524-4811
Mailing Address - Fax:802-878-6787
Practice Address - Street 1:1246 SUNSET HILL RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-9648
Practice Address - Country:US
Practice Address - Phone:518-524-4811
Practice Address - Fax:802-878-6787
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0018823367500000X
NY393924-1367500000X
MARN281492367500000X
NH059130-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009655Medicaid