Provider Demographics
NPI:1255006268
Name:PALMA, GAVIN
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:PALMA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 S LAS POSAS RD STE 254
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:137 S LAS POSAS RD STE 254
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2475
Practice Address - Country:US
Practice Address - Phone:760-760-7611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2025-04-10
Deactivation Date:2023-12-07
Deactivation Code:
Reactivation Date:2023-12-26
Provider Licenses
StateLicense IDTaxonomies
CAPT305216225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist