Provider Demographics
NPI:1174661011
Name:PACHECO, LISA LYA (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:LYA
Last Name:PACHECO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:LYA
Other - Last Name:LOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:805 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2104
Mailing Address - Country:US
Mailing Address - Phone:406-549-6600
Mailing Address - Fax:406-549-1511
Practice Address - Street 1:805 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-549-6600
Practice Address - Fax:406-549-1511
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1440204D00000X
MT11801204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
031093OtherANTHEM