Healthcare Provider Details

I. General information

NPI: 1144657156
Provider Name (Legal Business Name): MARC PALMONES VILLANO IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 HOSPITAL LOOP BLDG 9000
FAIRCHILD AFB WA
99011-8704
US

IV. Provider business mailing address

1610 S DEER HEIGHTS RD APT # L14
SPOKANE WA
99224-5191
US

V. Phone/Fax

Practice location:
  • Phone: 509-247-5661
  • Fax:
Mailing address:
  • Phone: 425-308-9586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: