Provider Demographics
NPI:1164418299
Name:PACHECO, ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:PACHECO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:407-650-1300
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:407-650-1300
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103334363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL201095753OtherTAX ID
FL003881800Medicaid
FLPA9103334OtherMEDICAL LICENSE
FLFG236ZMedicare PIN