Provider Demographics
NPI:1528586245
Name:PALM, KEVIN ALAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ALAN
Last Name:PALM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 WILD OAK DR
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-9168
Mailing Address - Country:US
Mailing Address - Phone:831-207-8443
Mailing Address - Fax:
Practice Address - Street 1:1650 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-983-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant