Provider Demographics
NPI:1609506781
Name:PACHECO, ISAAC ELIAS (CCP)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:ELIAS
Last Name:PACHECO
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 S INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:SELLERSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47172-1639
Mailing Address - Country:US
Mailing Address - Phone:763-228-3440
Mailing Address - Fax:
Practice Address - Street 1:959 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:SELLERSBURG
Practice Address - State:IN
Practice Address - Zip Code:47172-1639
Practice Address - Country:US
Practice Address - Phone:877-234-3266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFPF02000141242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist