Healthcare Provider Details

I. General information

NPI: 1003888629
Provider Name (Legal Business Name): KEITH CHRISTOPHER PALM RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL 1650 COCHRANE CIRCLE, ATTN: CREDENTIALS OFFICE
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

7922 BAYONET CIR APT B
FORT CARSON CO
80913-4686
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7844
  • Fax: 719-526-7984
Mailing address:
  • Phone: 719-559-4678
  • Fax: 719-526-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN505912L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: