Healthcare Provider Details

I. General information

NPI: 1053020172
Provider Name (Legal Business Name): WIL DANIEL PALMER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 CONGRESS ST
PORTLAND ME
04102-3112
US

IV. Provider business mailing address

818 CONGRESS ST
PORTLAND ME
04102-3112
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-8161
  • Fax: 207-773-1489
Mailing address:
  • Phone: 207-773-8161
  • Fax: 207-773-1489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2804
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: