Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QG0300X | Family Doctor - Geriatric Medicine | AP60979503 | WA |
Y | 363L00000X | Nurse Practitioner | AP60979503 | WA |
NPI | 1366095754 |
---|---|
Provider Name | Marcy Rene Pacheco |
First Address | Spokane, WA 99202-4932 |
Second Address | Spokane, WA 99205-1349 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2019 |
Last Update Date | 17/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
AP60979503 | WASHINGTON STATE DEPARTMENT OF HEALTH (01) |