Healthcare Provider Details

I. General information

NPI: 1851552459
Provider Name (Legal Business Name): RUSSELL LEON PALMER JR. RT, BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 WHITE SPAR RD
PRESCOTT AZ
86303-4236
US

IV. Provider business mailing address

1045 SCOTT DR
PRESCOTT AZ
86301-1731
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-9064
  • Fax: 928-777-9183
Mailing address:
  • Phone: 928-777-9064
  • Fax: 928-777-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberCRT-5873
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: