Healthcare Provider Details

I. General information

NPI: 1457788663
Provider Name (Legal Business Name): VIVIENNE N PALMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE BANEGAS

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/03/2021
Certification Date: 10/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD MAIL DROP 4S-205
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-455-6330
  • Fax:
Mailing address:
  • Phone: 858-824-5363
  • Fax: 858-964-3112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52309
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number52309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: