Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 11801 | MT |
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 1440 | ME |
NPI | 1174661011 |
---|---|
Provider Name | Dr. Lisa Lya Pacheco |
First Address | Missoula, MT 59801-2104 |
Second Address | Missoula, MT 59801 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2007 |
Last Update Date | 15/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
031093 | ANTHEM (01) |