Provider Demographics
NPI:1679230999
Name:PALMER, GARY LYNN JR (PTA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LYNN
Last Name:PALMER
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ZENITH DR
Mailing Address - Street 2:
Mailing Address - City:HEDGESVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25427-5732
Mailing Address - Country:US
Mailing Address - Phone:304-886-2373
Mailing Address - Fax:
Practice Address - Street 1:1008 TAVERN RD STE 200
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2801
Practice Address - Country:US
Practice Address - Phone:304-267-0866
Practice Address - Fax:304-267-8348
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPTA001913225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant